Purpose: We report a retrospective analysis of 20 patients with complex fracture of the distal radius treated in an emergency setting with an external fixation and complementary osteosynthesis.

Material and methods: These 20 patients, mean age 43 years, fifteen men and five women were treated between January 1998 and November 2000. The dominant limb was involved in 16 cases. There were ten manual labourers and four patients who had regular sports activities. The surgical procedure included manual reduction then application of an external fixator (Orthofix). The second time was for insertion of an anterior plate in nine cases. For seven patients, pinning was associated with the plate. Only eleven patients were treated with external fixation and pinning alone. Mean hospitalisation was ten days. Active rehabilitation of the fingers included daily exercises. All external fixators had been removed on day 45.

Results: Mean follow-up was 22 months. Clinically, mean outcome was: palmar flexion 40°, dorsal flexion 36°, radial inclination 12°, ulnar inclination 15°, pronation 75°, supination 62°. Force was often less than 20% of the contra-lateral side. Radiologically, mean results were: on the AP view radial tilt 23°, radioulnar distance +1 mm, mean radial; and on the lateral view, radial tilt −1.4°. Bone healing was achieved on day 45. Two patients developed severe reflex dystrophy. There were no infectious or skin complications. Two patients developed a carpal tunnel syndrome. The plate was removed in two cases. Two patients developed palmar dysaethesia. Two patients had a complementary procedure on the distal radioulnar joint due to defective supination. Eleven patients resumed their occupational activities at a mean six months.

Discussion: The purpose of this analysis was to determine, retrospectively, the role of external fixation of the wrist associated with complementary osteosynthesis in patients with complex fractures of the distal radius. These extra- and intra-articular fractures are difficult to treat and require minute analysis. Outcome in our patients indicated that this analysis is often incomplete before treatment. We had four patients with a stair-step joint surface due to defective primary reduction. The radius was usually well reduced in the frontal plane but the sagittal plane was rarely corrected. The radioulnar distance evolved unfavourably in eight patients reaching > +2mm. Our poorest results were in cases with external fixation and pinning. The best results were obtained with combined treatment using a plate, pins and the external fixator.

Conclusion: We advocate a very careful and rigorous analysis of the fracture, in agreement with the SOFCOT 2000 symposium concerning complex fractures, and prefer a triple surgical procedure using a plate, pins and the external fixator.

Purpose: We conducted a prospective preliminary study of ten cases of surgical repair of massive rotator cuff tears using a free quadriceps bone-tendon transplant. All procedures were performed between May 1998 and May 2000.

Material and methods: The series included seven men and three women (mean age 51 years 9 months). The dominant limb was involved in nine cases. Six of the patients were working. Mean duration of symptoms was 15 months (6–36 months). Mean preoperative Constant score was 49.1/100 points. The three most frequent signs were daily pain, limited amplitude, and loss of force. A MRI was obtained in nine cases and an arthroscan in one. There was a full-thickness tear of the rotator cuff with proximal retraction in eight cases and intermediary retraction in two. Fatty degneration (Goutallier-Bernageau) was basically grade II for the supraspinatus, and grade III for the infraspinatus. At MRI the tear measured more than 16 cm². Acromioplasty was performed in all cases, tenotomy and long-biceps tenodesis in seven. Sutures were made with Mersuture n° 2 using the Mason-Allen technique along the tear contour. The superficial portion of the quatriceps tendon was harvested via a longitudinal prepatellar incision. The quadriceps tendon was harvested with the trapezoidal patellar bony attachement. The free quadriceps tendon flap was sutured to the borders of the cuff and a bony tunnel was made to impact the bony attachment. Postoperative immobilisation was achieved with an abduction sling and a removable flexion brace for the knee. All patients participated in the centre’s rehabilitation programme and were reviewed at consultation. An MRI was obtained for five patients with the longest follow-up.

Results: Mean follow-up was 18 months. Mean Constant score at last follow-up was greater than 70 points. Mean force was less than 5 kg. The MRI obtained in five cases demonstrated a normal tendon with no signs of necrosis. There was one tear of the quadriceps tendon at the knee. This patient experienced persistent fatigability at 12 months.

Discussion: Treatment of full-thickness tears of the rotator cuff remains problematic, particularly in young active patients. Acromioplasty and bursectomy only provide pain relief. There is an ascension of the humeral head with an excentrated scapula. Classical transosseous reinsertion is not possible when there is major retraction. Certain teams advance the supraspinatus and the infraspinatus. Deltoid flaps only provide pain relief by their interposition in the subacromial space. Tendon transfer using the rectus is highly invasive and difficult to perform. The quadriceps tendon transplant is resistant and integrates perfectly in this reconstruction.

Conclusion: Repair of massive full-thickness rotator cuff tears in young patients with limited fatty degeneration remains a difficult challenge. For these patients, we propose repair using a free quadriceps bone-tendon transplant.