Purpose of the study: Fractures of the metacarpals are common injuries generally observed in young males. Nailing, either with a centromedullary configuration or intermetacarpal construction is generally proposed. The nailing procedure nevertheless has its drawbacks: fracture instability, secondary displacement, pin migration, infection, requirement to remove material, injury to the cutaneous dorsal branch of the ulnar nerve, and most importantly, immobilisation for several weeks which is a major inconvenience for these young active patients. In this context, we wanted to compare two fixation systems: a locked plate versus centromedullary nailing.

Material and methods: This was a retrospective comparison of consecutive patients from September 2007 to December 2008. The series included 39 cervical fractures of the fifth metacarpal in 39 patients aged 31 years on average. The first 19 patients were treated with a locked plate (Médartis^®) (group A) and the 20 others with descending centromedullary nailing (group B). In group A, a dorsal approach respecting the dorsal cutaneous branch of the ulnar nerve was used. The technique consisted in insertion of distal locking screws enabling fracture reduction on the plate. No postoperative immobilisation was proposed and rapid mobilisation was encouraged. In group B, classical centromedullary nailing was performed with immobilisation with a short Thomine brace and syndactylisation of the last two fingers. Outcome was based on objective criteria (Jamar^® force, joint motion, duration of sick leave) and subjective assessment (DASH, VAS).

Results: Mean follow-up was 12 months in group A and 8 months in group B. Depending on the type of fracture, plates with different shapes and lengths were used in group A; a single pin was used in group B (16/10 or 20/10). Secondary displacement was more frequent in group B, but the results in recovered motion were better in group B. The only parameter better in group A was length of sick leave; four patients in group A underwent reoperation to remove the plate and for tenoarthrolysis. In all, the outcomes for cervical fractures of the fifth metatarsal were better in group B.

Discussion: Our preliminary results in group A show lesser complications and earlier return to work compared with better motion at last follow-up in group B. Centromedullary nailing remains the better treatment for cervical fractures of the fifth metatarsal. The extra cost of the plates does not appear to be warranted for the treatment of neck fractures of the fifth even though the patient can resume occupational activities earlier.

Purpose of the study: Nonunion is a common complication of carpal scaphoid fractures. Incidence is 10% of all fracture types. No one technique has proven totally superior for the treatment of grade IIa and IIb nonunion of the carpal scaphoid (Alnot classification). In this study, we evaluated the contribution of percutaneous screw fixation for the treatment of these nonunions.

Material and methods: Our series included 26 patients with grade IIa (n=14) or IIb (n=12) nonunions. Outcome was assessed according to the clinical impact of the screw fixation and globally using the Quick DASH function score for the upper limb. Bone healing was assessed radiographically.

Results: Good outcome was good in 81% of the patients (93% for grade IIa and 68% for IIb) with the screw fixation, a healing rate similar to that obtained with classical techniques.

Discussion: Percutaneous screw fixation has the advantage of a mini-invasive approach and limits the risk of iatrogenic complications. It should thus be more widely used for the management of carpal scaphoid nonunions.

Purpose of the study: We reviewed traumatic distal leg amputations managed in our unit between 1990 and 1993. Reimplantation or unilateral emergency revascularization were undertaken in five cases.

Material and methods: The initial loss of length was considerable (range 8.5–12 cm) allowing direct internal fixation, protected with an external fixator bridging the ankle, and direct vasculonervous suture. Secondary lengthening was undertaken early in the proximal metaphyseal zone before sensorial recovery was complete.

Results: Healing was achieved within a normal delay in all cases. Nerve regeneration was monitored from the site of the microsuture by following the progression of the Tinel sign along the repaired nerve trunks; this defined the rate of regeneration. Our observations showed that nerve lengthening above the site of the microsurgical suture did not hinder nerve regeneration and even appear to stimulate it.

Conclusion: This strategy of extensive initial debridement compensated for by significant but well-tolerated secondary lengthening enabled us to broaden indications for unilateral leg reimplantations. The quality of the functional results at follow-up extending up to 15 years is probably one of the reasons justifying this strategy.

Purpose of the study: The role of injectable phosphocalcium cements for the treatment of fractures of the osteoporotic distal radius is poorly defined. Simple adjunction of a phosphocalcium cement to infrafocl pinning has not proven its efficacy. To improve this percutaneous technique, the purpose of this work was to study the contribution of prior metaphysodiaphyseal preparation by drilling to increase the quantity of cement injected and to improve is distribution on either side of the fracture line, with the hope of limiting the progressive degradation of the radioulnar index.

Material and methods: Sixteen patients aged 76.5 years on average (range 65–92 years) were treated starting in 2004 for fractures of the distal radius with posterior displacement and very porotic bone. After orthopedic reduction with external manoeuvres, three n°18 pins were introduced into the fracture focus percutaneously. After pin insertion, a fourth stab incision was made at the apex of the radial styloid process for insertion of a n°11 trocar which was advanced to the medial cortex without perforating it. The trocar was then removed to allow insertion of a curved pin for the purpose of drilling out the remaining bony network to the distal part of the shaft through to the subchondral bone. 20 mg Cementek LV® was then injected under fluoroscopic control. The postoperative protocol was as usual with an orthesis for six weeks and pin removal at six weeks.

Results: Mean follow-up was nine months. There were five complications which resolved (reflex dystrophy). On average, 4.6 ml was injected. There were eight cases of cement leakage which was «milked out» as much as possible via the skin incision. Leaks resorbed in a few months and did not have any clinical impact. At follow-up, clinical outcome (pain, strength, mobility, DASH), and radiological indices were satisfactory. Loss of the distal radioulnar index was 1 mm on average.

Discussion: This technique for drilling, cementing, pinning, appears to limit secondary displacements of distal radial fractures with osteoporotic bone. Cement leakage is not sufficient to contraindicate this method since all observed leaks resorbed spontaneously with no sequelae. Longer follow-up will be necessary to confirm these encouraging results.

Purpose of the study: Percutaneous osteosynthesis of scaphoid fractures remains a difficult technique which requires a long learning curve. Complications remain a problem, even in experienced hands of specialized surgeons. The purpose of this work was to study the potential contribution of fluoroscopic navigation for precutaneous screwing of the carpal scaphoid.

Material and methods: Right and left arm anatomic specimens from ten subjects were sectioned at the elbow level. Both wrists from each subject were prepared and each of the scaphoids was fixed by percutaneous screwing using regular fluoroscopic guidance for one and the other with fluoroscopic navigation. The regular fluoro-scopic guidance technique was used for the first wrist, selected randomly. Fluoroscopic navigation was used for the other side to achieve strict fixation of the wrist in the ideal screwing position using a stable radiotranspar-ent and flexible device. Using a calibraton grid displayed on the fluoroscope screen the system software corrected for distortions of the fluoroscope image. Reflecting patches on the surgical instruments were recognized by the 3D optical localization system. This enabled a real time screen display of instrument movement. Resolution was sufficient to align the screw with the scaphoid axis and calculate the length of the screw.

The resolution of the reformated digital images enabled real time screen display of instrument movement at a resolution which enabled pin insertion in the scaphoid axis. The length of the perforated screw inserted percutaneously over the pin was measured on the screen.

Results and discussion: Unlike the regular screwing method and excepting the image acquisition time which can be achieved without exposing the operator, exposure time to radiation was zero with fluoroscopic navigation. The duration of the operation was longer with navigation because the instruments had to be calibrated and because a learning curve is required. The quality of the screw fixation assessed on plain x-rays, computed tomography, and photographs of the entire scaphoid then sectional along the major axis after removal was similar between the two methods.

Conclusion: In conclusion, fluoroscopic navigation is a reliable technique which protects both the operator and the patient from radiation exposure. The technique remains to be standardized to shorten the learning curve, improve the navigation software, and develop a calibrated instrumentation before it can be used in routine clinical practice.