Introduction:

20 cases of bone defect have been treated by the induced membrane technique avoiding allograft, microsurgery and amputation

Introduction:

Tuberosity healing is strongly correlated with functional results in all series of three- and four-part fractures of the proximal humerus treated by hemiarthroplasty. We formed a working group to improve position of the implant and fixation of the tuberosities on an implant specifically intended for traumatology.

Introduction

20 cases of bone defect have been treated by the induced membrane technique avoiding allograft, microsurgery and amputation

The treatment for trochanteric femoral fractures is still challenging. Since 2005, we are using 2 new implants: Gamma3™ nail and the PFN-A™.

All patients with a fracture of the trochanteric area were included in an observational study during 3 years.

Objectives were radiographics and clinics (complications) comparaison of these 2 new devices.

We included 426 patients (236 Gamma3™ nails, 190 PFN-A™). We faced the epidemiological data, per and post-operative complications. The tip-apex distance and the position of the cephalic implant were studied.

The 2 implants were well positionned in more than 80%, with no statistic diffferencie. We found a a cut-out rate of 1,4 % and a re-operation rate of 4,9 %. These rates of usual complications are very low in comparaison with litterature. We did not found a statistic difference between these 2 differents nails.

But, we observed 2 unusual complications: for the Gamma3™ nail, a high rate of automatic distal locking failure, and for the PFN-A™, many patients complained of thigh pain resulting from a prominent cephalic blade. These 2 new complications can be avoided by small changes in the operative procedure.

In our mind these 2 implants can be used for treating all patients with trochanteric fracture, but we need other studies to compare these nails with the new generation of sliding plate

Purpose of the study: Management of bone and joint infections is a recognised public health concern recently labellised by the establishment of Reference Centres and associated Reference Centres. Among other objectives, these Centres are designed to develop pluridisciplinary expertise in the form of recommended clinical practices (French Health Ministry directive DHOS, May 2008).

Material and methods: In response to this tender, a weekly pluridisciplinary meeting was instituted in March 2008 with an orthopaedic surgeon, an infectious disease specialist, an anaesthetist, a pharmacist, microbiologists, a rheumatologist and a diabetologist. The activity and impact on antibiotic consumption in the functional unit of septic surgery was evaluated over a one-year period.

Results: From March 2008 to March 200, 35 pluridisciplinary meetings were held and analysed 243 files concerning 133 patients. This consensual approach led to a decrease in the antibiotic consumption in the functional unit. This consumption was 1222 DDJ/1000 days hospitalisation during the last semester of 2007 and 1069 DDJ/1000 days during the last semester of 2008 (p=0.005). During this same period, the activity in the unit increased from 37 patients with infected material (CIM 10 T 84) in 200 to 58 in 2008 and from 27 patients with septic arthritis (codeM00) to 42 in 2008. Similarly the number of indexed pathological conditions in this unit increased from 447 to 548 in 2008 with a fall in the mean duration of the hospital stay from 11 days in 2007 to 9.6 in 2008. The improvements provided by the process of intraoperative sampling provided bacteriological documents in 85% of cases. The analysis of antibiotics prescribed in the functional unit showed a decline in the consumption of antibiotics with week or unknown distribution in bone (amoxicillin + clavulanic acid: −13%; pristinamycin: −72%) and an increase in the prescription (before adaptation to documented bacteriological results) of the association cefotaxime+fosfomycin (5-fole increase in one year).

Discussion: This study clearly shows how important regular pluridisciplinary discussion is needed to optimise the management of bone and joint infections and that this approach improves the antibiotic prescription and shortens the hospital stay.

Conclusion: This experience proves the pertinence of the Reference Centres and the associated Reference Centres, both economically and medically.

Purpose of the study: Volar plate fixation is becoming increasingly popular for instable fractures of the distal radius or on porotic bone. We report our experience and unavoidable or predictable complications with this type of fixation.

Material and methods: The 142 patients who underwent surgery from 2006 to 208 were reviewed and followed prospectively. In 2006 and 200, three types of volar plates were implanted: the Ace Depuy (standard), the T or DRP (Synthes), prolock with locking screws, (ITS) with a series of 104 patients. In 2008, two types of new generation plates with a more anatomic design were used: Variax (Stryker) and Newclip with a series of 48 patients. Complications were noted with minimum four months follow-up.

Results: All fractures healed. The Herzberg score reached 81/100 and the DASH 19.4. The complication rate was 19% (n=19) for the older generation plates and 15% (n=7) for the new anatomic plates. The main complications were tears of the long flexor and long extensor pollicis tendons (two before 2008 and four after 2008), reflex dystrophy (five before 2008 and two after), carpal tunnel syndrome (n=4), and material problems (dislodged screw, protruding screw) with no functional consequences (six before 2008 and one after).

Discussion: The increasing popularity of plate fixation for distal radius fractures generates an increase in complications. These are predictable if the material protrudes (tendon tears caused by overly long screws). Three published series on these specific complications (Rozental 2006, Rampoldi and Arora 2007) found that these problems could be avoided, both by implant design and by surgical technique. Locking the epiphyseal screws requires insertion into the subchondral bone and thus distal implantation of the plates, generating an iatrogenic conflict for the flexors. The rediscovery of the anatomy of the distal radius should help avoid styloid problems, and reconsideration of plate design to avoid advancement both on the ulnar side and the radial side. While the extra-articular volar plates fulfil the same function as pinning (Obert 2006), plates have lower indirect costs than pinning + plaster cast (Candelier 2006). Conversely, there is still no proof of the superiority of locked screws over standard screws.

Purpose of the study: Since the advent of locked centromedullary nailing, manufacturers have produced long nails with automatic distal locking systems. Astute instrumentations have been developed to achieve highly stable assemblies. But during insertion, the exact shape o the nail may change adapting to the anatomy of the medullary canal. We wanted to test a new automatic distal locking system: Surelock.

Material and methods: We conducted a preliminary monocentric prospective study over a one-month period where we included all cases of reconstruction of the proximal femur using a long nail. The Surelock system was applied systematically. The amplifier was needed to adjust the insertion device, the amplifier and the nail in the same plane. This configuration required manipulation of the amplifier in a single plane. The operator then had to correct the position of the insertion devise in accordance with the deformation of the inserted nail. It is noteworthy that with this system, the operator’s hands are never in the amplifier field. We measured the time required to achieve distal locking and the time of scopy, as well as any complications.

Results: During this period, ten patients had osteosynthesis with a long reconstruction nail. The epidemiological data were common for this type of condition. Mean time for the distal locking was 11 min (7–15) with a mean 17 s of scopy (2–24). In all cases, the two distal screws were inserted. The automatic locking was correct in 9 of 10 cases. The one failure was the second case in our series.

Discussion: In 2006, Whatling concluded a review of the literature on different means for distal locking that the search should continue for an ideal method and that by far the most widely used method was manual locking. The new method presented here for automatic distal locking allows implantation of two distal safety screws. The main benefit is for the surgeon and the manipulator of the amplifier. Radiation of the surgeon is nearly zero (the surgeon remains outside the amplifier field) and the manipulation to position the amplifier is simplified.

Conclusion: We believe that this technique could be used in routine practice and that this method could be proposed for the entire range of nailing procedures.

Purpose of the study: The purpose of this work was to analyse the respective complications of nail fixations for trochanteric fractures. Since January 2005, we have used the Gamma3™ and the PFN-A™ in routine practice. These nails have evolved and we wanted to compare the latest generation models.

Material and methods: This was a prospective consecutive series of 426 files in a single centre (January 2005 to October 200) reviewed at mean 19 months (3–36 months). All patients with a fracture of the trochanter treated by osteosynthesis were included. Eight senior operators implanted Gamma3™ nails (4 operators) or PFN-A™ nails (4 operators). During this period, 236 Gamma3™ and 190 short PNF-A™ nails were implanted. The two cohorts were statistically comparable regarding: mean age, body weight, ASA score, preoperative autonomy, repair of fracture type.

Results: There was no significant difference between the two implants for: implant position (correct position for 80%), early mortality (5.5%), rate of sepsis (1.6%), which were comparable with the literature. In these two groups, the operative time was shorter than in the literature with an advantage for the PFN-A™ (40 min versus 35 min). Sliding was minimal (1.3% for Gamma3™ versus 1.1% for PFN-A™), as was revision (5.1% versus 4.7%). Conversely, the technical complications were implant dependent: defective automatic distal locking for the Gamma3™ (n=24, 10.2%) with fracture on nail for four patients, and protrusion of the cephalic blade for the PFN-A™ (n=11, 5.8%) due to insufficient impaction and to back glide after excessive distraction followed by impaction.

Discussion: There is a rich body of knowledge on the different nail and screw-plate models. Mean sliding is to the order of 4% and mean revision about 8–9%. We could not find a study comparing the new implant generations. These implants enable a reduction of the general complications for trochanteric surgery, but to ensure persistent results, care must be taken for the distal locking of the Gamma3™ and the intraoperative protrusion of the PFN-A™ blade.

Introduction: Humerus non union is unfrequent, and reported series short. New fixation with or without autograft remain the gold standard to achieve bone union in 95% of cases. But no report are published in case of failure of that new procedure. 9 patients with a failure of autograft in humerus non union have been treated by new fixation an adjonction of BMP

Matériel et méthodes: 9 patients with an average age of 53,8 yo (24–71) have been treated and followed prospectively for a minimum time of 3 years. The delay between the fracture and the secon procedure was 31 months (6–103). The number of procedure after the fracture fixation was 1,4 (1–5). In 6/9 cases a technical pitfall during the initial procedure was pointed. In 3/9 cases a radial palsy associated with the initial fracture, a septic condition of the non union, general risk factors of non union (diabetes, tabac) and a non collaborative patient were reported.

Bone union was defined as the continuity of 4/4 cortex on Xray (AP and sagital plane) and or with ct scan. Osigraft^® (BMP7) was implanted in the resected zone of non union which was fixed with 2 plates after reaming and decortication.

Résults: No complication have been reported. One case failed (septic non union, 3 procedures, very active patient). The 8 last patients achieved bone union with a delay of 11,1 mois (6–14) without any additive procedure. The 3 septic cases have been solved. Shoulder and elbow function were good without nerves complications.

Discussion:: Autograft remains the gold standard in term of treatment of non union. But nothing is reported in humerus non union if iliac crest autograft have failed to achieve non union. In such an indication (failure after an autograft) and in such a level (humerus can be shorten) a stable fixation an a growth factor allowed to solve resistant cases of non union even in septic conditions.

The failure of the initial treatment of the fracture (unstable fixation, unfilled bone’s defect) remain the main cause of non union.

Introduction: The three or four-part fracture of the proximal humerus remains a challenging fracture in the case of elderly patient. In this continuing prospective study we compared the outcome after implantation of a shoulder hemiprosthesis of the anatomical generation and a reversed prosthesis.

Material and methods: 34 shoulder prosthesis were implanted in patients older than 70 between june 1996 and june 2004. All patients were evaluated by a surgeon not involved in treatment concerning activities of daily living (DASH scoring), clinical outcome (Constant-Murley Score), radiological results, and a summary of complications.

Group 1: anatomical prosthesis (Tornier): At an average follow-up of 16,5 (range 6–55) months, 13/17 patients with an average age of 78,6 years (70–95), were evaluated.

Group 2: reversed prosthesis (Depuy): At an average follow-up of 12,6 (range 6–18) months, 13/17 patients with an average age of 77,1 years (70–84), were evaluated. In this group functional treatment was started immediately after surgery.

Results: concerning age, follow up and dash scoring there were no difference between two groups. In reversed group : the outcome was better (Constant-Murley: 79,5 (57,8–100) vs 57,1 (21–85) p=0.005), the average active elevation was better by 30° (p< 0.001) and the average active abduction was better by 53° (p< 0.001). 7/13 cases of glenoid notching stage 2 or 3 were noted. In anatomical group : the average active external rotation was better by 10° (p=0.01). Tubercle fixations failed in 6/13 cases.

Discussion: No comparative study has still been published between the two sort of implant in elderly patients. Our results of shoulder arthroplasty in acute injury to the proximal humerus with reversed prosthesis are in agreement with the preliminary results reported by Sirveau. At short follow up, reversed prosthesis allow to reach early mobilisation with best functional results. Rotation remains the key point : with a significant gain in active abduction and elevation the reversed prosthesis group do not reach a better dash scoring. Attachment fixation of the posterior rotator cuff must probably be discussed in reversed prosthesis in acute fracture.

PURPOSE: To compare the functionnal and radiological results concerning the “same” distal radius fracture of 3 different and consecutive procedure : dorsal plate, pins and palmar plate.

MATERIAL AND METHOD: Sixty two patients with a dorsally displaced extra-articular fracture of the distal radius were treated by dorsal plating [group 1, 20 patients, mean age 59,9 yo (25–87)], pinning [group 2, (22 patients, mean age 55,6 yo (17–83)] and volar plating [group 3, 20 patients mean age 57,1 yo (17–78)]. Patients were evaluated by a surgeon not involved in the treatment. Posttreatment evaluations consisted of measurements of range of motion, grip strength, radiographic evaluations between post operative time and last follow up, and evaluation by Herzberg scoring, associated with Gartland and Werley rating system and completion of Disability of Arm, Shoulder, and Hand questionnaires. Comparaison of three groups was performed with Kruskall-Wallis or ANOVA test (quantitatives variables) and Khi-2 (qualitatives variables) (p-value < 0.05).

RESULTS : Operative time was same for plate groups but two times more than pin groups. In Group 1 most complications and fair functionnal results were reported (32%) in spite highest follow up. Group 3 showed best results in flexion-extension, with DASH scoring, ulnar variance conservation, and most excellent and good results with Gartland and werley rating system. In group 2 and 3 same percentage of complications were pointed: 5%. Indenpendtly of tretament best results were reported in men, less than 30 yo.

DISCUSSION : If dorsal plate remains logical, such a fixation is challenging with high percentage of complications. In such extrarticular distal radius fracture palmar plate as pinning reach good and reliable functionnal results. Reduction of the palmar cortex remains probably the technical point. If the palmar plate is sufficiently rigid it can offer adequate stability for the treatment of the distal radius fracture in which the anterior and/or posterior metaphyseal cortex is frequently comminuted severely.

Introduction: Occult fractures of carpal bones are underestimed. To be treated succesfully fractures of the scaphoid must be identified at an early stage. A delay in detection may result in non union. We validated with 3 prospective studies a new tool using scintigraphy : The quantitative Xray bone scan (QRS)

Material and Methods: A previous preliminary prospective study with 60 patients was performed and published to valid the QRS as a step in diagnosis of wrist occult bones fractures equal to RMI. This exam is a bone scan with 2 improvments.

1) A quantification of the fixation spot : If the spot is two times more important on the injuried wrist (than controlateral side) the fracture is sure.

Result: Between november 97 and march 04, 667 patients were enrolled in a prospective continue study. 40% (260/667) of patients with an injury of the wrist with normal X ray sustained an occult fracture. QRS was performed at an average of 17,7 days after the injury and after clinical exam and repeat set of scaphoid view. Scaphoid fractures were most frequent. Fixation was most important if scintigraphy was performed between 11 and 20 days after the injury. Fixation did not depend on age, sex, volume of the bone, and delay (after 15 days).

Discussion: As Dikson, Dias, Thompson, and Kuckla, repeat set of scaphoid view are unable to improve significativally the number of occult fractures of the wrist. RMI as reported by Kuckla can reduce the need for further imaging procedure. RMI and scintigraphy are both the best exam to diagnose surely an occult fracture of the wrist. But QRS does not over diagnose, as RMI, bones fracture’s.

Conclusion: “Plaster cast and wait” is not the treatment for occult carpal bones fracture’s. The quantitative Xray bone scan is able to diagnose such fractures with short delay.

Objective: 6 cases of postraumatic arthritis of the distal radius treated by chondro costal graft are reported with a minimum follow up of 2 years

Material and methods: 6 patients (One 22 years old patient with a dislocated radiocarpal joint 6 months after an injury, 3 patients (48, 52 and 53 years old) respectively 1, 1,5 and 2 years after a intraarticular fracture of distal radius and a patient (74 years old) with radio lunate arthritis reported two mains complaints : pain and stiffness. The last patient was a female with a destruction of radio scaphoid joint after septic complication of scaphoid surgery. Location of the cartilage defect was central in two cases and palmar in the others. A dorsal approach in one case, a palmar approach in the five others allowed reduction and reconstruction of the destroyed radial part of joint. An osteochondro costal graft harvested on the eight’s rib was inserted and fixed by plate in place of the articular impaction. Plaster cast of 3 months in the first case and 1 month in the others cases followed the articular reconstruction

Results : No complication have been pointed. Union was achieved in all 6 cases. Integration and viability of the graft were evaluated with RMI. At the highest follow up functionnal result are excellent in the youngest first case (male, 22 years old) where motion and grasp are similar than the controlateral side. In the 4 others cases of mal union patients were pain free in daily activity with a functionnal wrist score of 72/100 (54–82) and a DASH of 38,3 (22,5–51,7). Only the case with the septic problem failed with pain at follow up.

Conclusion: Reconstruction of a partially destroyed articular surface by a costal graft is reliable and allows filling and resurfacing an articular cartilage void. If chondro costal graft is currently used in maxillo facial surgery it is the first report in post traumatic arthritis secondary to intra articular mal union.

Objective: The purpose of the present study was to report on the author’s experience using injectable cement as a bony substitute in distal radius corrective osteotomies. The interest of such a bone substitute is the real capacity to adapt itself to the bone defect. Harvesting a trapezoidal cortico spongious graft which can fill very precisely the void and not more remains a challenging objective in treating extra articular mal union.

Material and Methods: 5 patients with an average age of 57 yo (42–74) had a corrective osteotomy for a malunited distal radius fracture using Injectable bone substitute (Eurobone, Jectos, Kasios Inc) as an alternative to an autogenous bone graft. Internal fixation of the osteotomy was achieved by using one plate without post operative immobilisation. Two patients were stiff at preoperative time.

Results: At an average follow-up evaluation of 26 months (14–37 mo) all the osteotomies united. Wrist flexion-extension motion improved from 56° to 110°, forearm rotation increased from 112° to 142°, and grip strength had an average increase of 120% at the time of the final follow-up evaluation. All patients were satisfied but there one report of persistent pain. Radiographic evaluation showed an average volar tilt improvement from a preoperative dorsal angulation shifting into a neutral position in the sagittal plane; Radiographically the injectable cement showed evidence of progressive re-absorption over time but with no complete disappearance.

Conclusions: On the basis of this preliminary experience it is reasonable to consider injectable cement as a viable alternative to bone grafting in conjunction with surgical correction and internal fixation of extra articular distal radius malunion.

Purpose of the study: Reinsertion of the brachial biceps on the radial tubercle has been an effective method for recovering cyclic supination. Several surgical techniques have been proposed but only one clinical evaluation of operated patients has been published. We report the first study of a clinical and magnetic resonance imaging (MRI) assessment of brachial biceps reinsertion in the anatomic position using an anchorage system. The purpose of this work ws to determine whether the reinserted biceps remains inserted and to analyze the zone of insertion.

Material and methods: Nine manual laborers underwent surgery between 1999 and 2003 for repair of a ruptured brachial biceps by reinsertion on an anchor. The patients were reviewed by an independent operator (measurement of force and flexion). A 3-Tesla MRI machine was used to evaluate the position of the reinserted biceps. Reinsertion was performed within 5 days of injury (range 3–9 days) using the same technique of anchorage in the radial tubercle in all cases. A longitudinal incision measuring 3–5 cm along the medial border of the radial brachial was made to localize the ruptured biceps and the radial tubercle and drill two or three insertion holes for the anchors. The suture threads were used to bring the brachial biceps tendon progressively to the anchor used as a pulley before knotting. The patients were immobilized for three weeks, limiting flexion to 0–90°, then 45–130° the three following weeks.

Results: For the nine patients, there were no cases of sepsis nor radioulnar synostosis. Three cases of calcification were noted and to cases of nervous complications which resolved totally. Six patients, mean age 44.8 years (range 34–54 years) (two patients had moved away from the region) were reviewed at mean 19.2 months (range 10–33 months). Force at maximum flexion was 94.6% of the opposite side (range 58–131.5%). Repeated supination was somewhat bothersome for two patients. None of the patients complained of work impairment and all resumed their activity at the same level within 4.6 months on average. The MRI analysis (available in five patients) demonstrated that the reinserted tendon was in contact with the bone and that ther was a visible bone-tendon junction: the anterior and posterior borders of the tendon, as well as the fivers, showed a regular configuration. The terminal part of the tendon was enlarged in 3/5 cases. The tendon signal from the last 3 cm was variable: low intensity signal on T1 and T2 sequences or discrete high intensity signal on T1 and T2. There was no evidence of peritendinous effusion. At the time of the MRI evaluation, the anchors had not been resorbed.

Discussion: Several studies have reported the usefulness of reinserting the branchial biceps in manual laborers. The half-approach techniques, especially by anchorage, avoid the double-approach, enabling less traumatic reinsertion. The branches of the radial nerve must be carefully identified (we observed only resolutive cases of nervous deficit). Nevertheless, this type of reinsertion has not been evaluated. There is no proof that the reinserted biceps remains in an anatomic position. Our MRI findings are in favor of continuing the single-strand suture technique since the evidence demonstrated the validity of this type of transosseous suture.

Purpose of the study: Functional recovery afte displaced cephalotuberosity fracture of the proximal humerus in pateints aged over 70 years is a major surgical challenge. Reconstuction with an inversed prosthesis avoids the problems of tuberosity fixation. We report a prospective consecutive series of reversed prostheses used of 3 and 4 fragment displaced and non-displace fractures in patients aged over 70 years.

Material and methods: Between January 2001 and June 2004, 19 patients aged over 70 years were included in this study, 16 women and 3 men, mean age 74.9 years (range 58–94 years, median 76 years). All presented 3- or 4-fragment fractures. An independent operator established the Constant and Dash scores. The position of the implants, loosening, presence of a glenoid notch (Nerot) were noted on plain x-rays.

Results: Sixteen of the 19 patients (13 women, 3 men), mean age 73.9 years (range 58–94 years) were reviewed at mean 12.6 months follow-up (range 6–18 months). There were no cases of dislocation. Hematogenous sepsis occurred at 16 months in one patient and led to implant removal. The raw Constant score was 53 (34–76) and the weighted Constant score 76.1 (41–110.1). The Dash score was 37.4 (34–76). Active abduction reached 91.2° (10–150°), active elevation 97.5° (20–150°), active RE1 6.6° (0–50°), active RE2 9.4° (0–90°) and active internal rotation 31.2° (0–60°). There was a humeral lucent line in five cases and a grade 0 glenoid line in one, grade 1 and 2 in six, and grade 3 in three.

Discussion: The only series of fracture of the proximal humerus in patients aged over 70 years was a retrospective study of prosthesis patients reported by Wretenberg in 1997. To date, there has not been a published series on use of the reversed prosthesis for fracture. For the short term in a population with frail bone and minimal functional requirements, reversed implants provide the best subjective and objective functional results. The absence of postoperative immobilization and independence from the rotator cuff enables rapid recovery of useful motion. Range of motion is reduced only to a small extent for rotation. Thus when possible, we reinsert the tuberosities with the reversed implant. Even if the tuberosity assembly dismounts (agitation in a context of temporospatail disorientation), there is no consequence on the reversed prosthesis. The large number of lucent lines with no clinical impact is a point to be examined carefully, showing that further improvement can be achieved with the existing implants.

Purpose of the study: Locked centromedullary nailing has proven efficacy for the treament of tibial shaft fractures but its use remains controversial for the most distal fractures. The purpose of this work was to assess clinical and radiological outcome of nailing procedures used to treat fractures of the lower quarter of the leg.

Material and methods: Fifty-eight fractures of the lower quarter of the leg were treated by locked centromedul-lary nailing between 1999 and 2002. All patients were included in the analysis. Twenty-four patients aged 44 years on average (range 18–68 years) were reviewed by an independent operator at mean 43.2 months follow-up (range 18–70). Four types of nail were used, on an orthopedic table for 47 procedures and with a hanging leg for 11. The fibula was not fixed.

Results: Early complications were: compartment syndrome (n=2) and infection (n=3). Postoperative alignment was anatomic or good in 86%. Mean time to weight bearing was 66 days (range 0–180). Nonunion occurred in six patients who required revision. Secondary displacement was noted in ten patients. Knee motion was normal in all patients and ankle motion was normal in 80%. Mean time to resumed occupational activity was 5.7 months (range 1–18). At last follow-up, bone healing had been achieved in all patients.

Discussion: As compared with data in the literature, we found that locked centromedullary nailing allows early weight bearing with less risk of infection for radiological results comparable with those obtained with plate fixation. The secondary displacements resulted from defective locking of inappropriately adapted materials (holes insufficiently distal).

Conclusion: Locked centromedullary nailing is a treatment of choice for fractures of the distal quarter of the leg. Use of new nails with more distal holes should improve outcome by allowing distal locking with at least two screws in all cases.

Purpose of the study: Occult fractures of the carpal bone are underestimated. An undetected fracture of the scaphoid will not be immobilized and will lead to nonunion and osteoarthritic degradation. In order to avoid late diagnosis and functional loss, in addition to lost chances and legal suites, we validated a quantitative radioscin-tigraphic (QRS) tool in a randomized prospective trial conducted from 1997 to 2003 in a routine practice setting. The series included 667 patients with wrist trauma presenting a normal plain x-ray one day 0. After day 8 these patients underwent QRS.

Material and methods: The principle of the technique consists in a classical technetium scintigraphy with two technical improvements:

quantification of uptake: uptake two-fold greater on the injured side is a sign of «certain» fracture;

Results: Forty percent of the wrist trauma patients (260/667) with a normal plain x-ray presented an occult fracture (uptake > 2 on QRS). QRS was performed on day 17.7 on average. Fractures of the scaphoid were the most frequent (42%). The uptake ratio was higher if the QRS was performed from day 11 to day 20. Statistical analysis showed that uptake ratio > 2 was independent of age, gender, bone volume, and time to QRS.

Discussion: As demonstrated by Dikson, Dias, Thomp-son and Kuckla, repeated x-ray images do not increase the rate of diagnosis of carpal bone fractures. Spitz demonstrated that scintigraphic uptake on the trauma side more than twice that on the healthy side is a sign of fracture. Garbuio, NOvert and Lepage validated QRS as a sensitive and specific diagnostic tool for occult fractures. They demonstrated that QRS is less costly, more reliable than MRI and that there are no false positives.

Conclusion: Exploration of a «bone problem» in a patient with wrist trauma must not ignore sensitive and specific tests. Ultrasonography is operator-dependent and requires validation. We thought that QRS would not resist the development of routine MRI, but observed the contrary. QRS remains the gold standard diagnostic tool for ruling out a fracture of the carpal bones.

Aim: Treatment of unrecons tructible comminuted fractures of the radial head remains a therapeutic challenge. There is limited information on the outcome of management of these injuries with metal radial head implant. Before choosing one of them, two groups of patients were rewieved in a retrospective study comparing resection and Swanson implant.

Material and methods: 39 patients sustained unreconstructible radial head fracture between 1969 and 1992. Two groups of 24 patients were reviewed clinically and radiologically by a surgeon not involved in treatment. Functionnal outcomes of the elbow (morrey scoring – SOO scoring system, instability, cubitus valgus) and involvement of the wrist (pain, grasp, RUD instability) were evaluated with a mean follow up of 15 years (6–27,7). Elbow or wrist arthritis, ulnar variance, and evolution of Swanson implant’s were evaluated on standard Xray. 1/2 patient was a man and 1/3 cases consisted in a professional injury. Resec tion group: 16 patients with a mean age of 39 (19–65), treated with a mean preoperative delay of 29,6 days (0–150) were rewieved with a mean follow up of 18,9 years (6–27,7). There were 75% Mason type-III injuries associated with dislocation of the elbow in 18% cases. Swanson group: 8 patients with a mean age of 36 (21–57), treated with a mean preoperative delay of 4,1 days (0–15) were rewieved with a mean follow up of 12 years (8,1–20). There were 88% Mason type-III injuries with no dislocation in that group.

Results: The following criteria did not show any significant differences between both groups: Morrey scoring 77/100, SOO scoring 7,4/11, mean flexion was 130°, mean deficient extension was 18°, mean pronation 60°, mean supination 67°, grasp reached 90% of the contralateral side. Arthritis was pointed in same frequency at the elbow level (87%), and wrist level (66%) in each group. 94% of pa tients in resection group and 89% in Swanson group were satisfied. Excellent and good results are reported most frequently in Swanson group (37% resection group, 51% Swanson group). In resection group following complications were significantly more frequent: ulnar nerve irritation (2x), ulnar head dislocation (2x), ulnar head instability (3x), paraarticular ossification (5x), ulnar variance positive in all cases (mean value 3,20 mm). In the Swanson group only one implant was destroyed at the follow up.

Aim: The purpose of the study was to evaluate the feasibility of Norian SRS bone cement injected into a distal radius following reduction and stable fixation in preventing shortening and loss of pronation-supination.

Material and methods: Between 1998 and 2000 48 patients with a mean age of 65 (54–82) sustained distal radius fracture (AO classification stage A in 26 cases, B in 15 cases, C in 7 cases) with metaphyseal comminution. Functionnal and radiological outcomes of the wrist (O’ Brien scorring, Gartland and Werley scoring, DASH) were evaluated with a mean follow up of 46 months (36–56) by a surgeon not involved in treatment. Fixation was performed in 34 cases by pins, in 14 cases by dorsal plate, in 2 cases by external fixator.

Results: 4 patient lost of follow up and 5 mal union were excluded of final evaluation. 3 RSD were pointed on the 39 evaluated patients. O’ Brien scoring reached 84/100 (54–100), Gartland and Werley scoring reached 4,6 (0–11) with 89% excellent and good results, DASH reached 23,6 (5,8–62,7). Ulnar variance changed less than 2mm between postoperative time and maximal follow up in 88%. There were no clinically adverse effects but one case of volar extrusion of injected Norian was pointed with resolutive evolution. Bone substitute was always in place at the longest follow up.

Discussion: Adams, Pogue, Mc Queen pointed the bio-mecanical and clinical advantage to fill the void secondary to the comminution to avoid the shortening of the radius. First cases reported by Kopylov and Jupiter, and prospective series of Kopylov, Sanchez Sotello and Cassidy proved the interest of an adaptative injectable cement in case of comminution. Injectable bone substitute allows to maintain the ulnar variance in competition with bone graft or bio ceramic.

Conclusion: Norian is able to fill a metaphyseal void but fixation of the fracture remains necessary.