Previous clinical studies have shown the efficacy of a foreign body-induced membrane combined with bone autograft for the reconstruction of traumatologic or pathologic large bone defects or, bone non union. This membrane, rich in mesenchymal stromal cells (MSC), avoids bone autograft resorption and promotes consolidation by revascularisation of the bone and secretion of growth factors. Reconstruction requires two different surgical stages: firstly, insertion of a cement spacer in the defect, and secondly, removal of the spacer, preservation of the foreign body-induced membrane and filling of the cavity by bone autograft. The optimal time to perform the second surgical stage remains unclear.

So, we aimed to correlate bone healing and, phenotype and function of cells isolated from the induced membrane, in patients whose second surgery was performed on average after 6 months (i.e. beyond the recommended time of one month). Cell phenotype was determined by flow cytometry and cell function by: alkaline Phosphatase enzyme activity, secretion of calcium and von Kossa staining. Second, using histological and immunohistochemistry studies, we aimed to determine the nature and function of induced membrane over time. Seven patients were included with their consent.

Results showed Treated patients achieved in all cases bone union (except for one patient) and in in vitro and histology and immunohistochemistry gave some indications which need to be completed in the future. First, patient age seemed to be an indicator of bone union speed and recurrent infection, appeared to influence in vitro MSC osteogenic potential and induced membrane structure. Second, we reported, in bone repair situation, the commitment over time in osteogenic lineage of a surprising multipotent tissue (induced membrane) able of vascularisation/ osteogenesis/ chondrogenesis at a precocious time. Finally, best time to perform the second stage (one month) could be easily exceeded since bone union occurred even at very late times.

Used routinely in maxillofacial reconstructive surgery, the chondrocostal graft is also applied to hand surgery in traumatic or pathologic indications. The purpose of this overview was to analyze at long-term follow-up the radiological and histological evolution of this autograft, in hand and wrist surgery. We extrapolated this autograft technique to the elbow by using perichondrium.

Since 1992, 148 patients have undergone chondrocostal autograft: 116 osteoarthritis of the thumb carpometacarpal joint, 18 radioscaphoid arthritis, 6 articular malunions of the distal radius, 4 kienbock's disease, and 4 traumatic loss of cartilage of the proximal interphalangeal (PIP) joint. Perichondrium autografts were used in 3 patients with elbow osteoarthritis.

Magnetic Resonance Imaging (MRI) was performed in 19 patients with a mean follow-up of 68 months (4–159). Histological studies were performed on: i) perioperative chondrocostal grafts (n=3), ii) chondrocostal grafts explanted between 2 and 48 months after surgery (n=10), and iii) perioperative perichondrium grafts (n=2).

Whatever the indication, the reconstruction by a chondrocostal/ostochondrocostal or perichondrium graft yielded satisfactory clinical results at long-term follow-up. The main question was the viability of the graft.

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For rib cartilage grafting: The radiological study indicated the non-wear of the graft and a certain degree of ossification. The MRI and histology confirmed a very small degree of osseous metaplasia and graft viability. The biopsies showed neo-vascularization of the cartilage that had undergone morphological, constitutional and architectural changes. Comparison of these structural modifications with perioperative chondrocostal graft histology is in progress.

Despite the strong mechanical strain in the hand and wrist, chondrocostal graft is a biological arthroplasty that is trustworthy and secure over the long term, although it can cause infrequent complications inherent to this type of surgery. Despite the inevitable histological modification, the cartilage remains alive and is of satisfactory quality at long term follow-up and fulfills the requirements for interposition and reconstruction of an articular surface.

The perichondrium graft constitutes a new arsenal to cure cartilage resurfacing. The importance of perichondrium for the survival of the grafted cartilage, as previously reported, as well as its role in resurfacing, is being investigated.

Introduction:

90 cases of reversed prosthesis have been evaluated and the aim of the retrospective multicenter study was to correlate the functional and radiological results depending on the type of implant.

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

Summary

Properties of human amniotic membrane are particularly interesting. To use it as an Advanced Therapeutic Medicinal Product in bone surgery, we are evaluating its association with a potentially osteoinductive scaffold.

Summary

Human amniotic membrane has interesting properties for regenerative medicine. To use it as an Advanced Therapeutic Medicinal Product in bone surgery, we are evaluating: the necessity of its osteodifferentiation and the impact on immunogenicity; its optimal condition for storage.

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: 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: Trapeziometacarpal prosthesis allows to reach faster mobility and usefull thumb than trapeziectomy. But successfull Implantation of the trapezium cup depends on the bone stock and the jig. An anatomical and biomechanical study is presented followed by a prospective clinical evaluation of the impllantation af a screwed trapezium cup to define the best way to reach the center of the trapezium.

Matériel et méthodes: Cadaver study: 11 screwed trapezium implant have been implanted on cadaver (age > 70 yo, alcool conservation). 5 implants with 5 spires and 6 implants with 3 spires have been tested. Extraction tests have been performed after Xray evaluation of the position of the implant. 2 series of test were done in the subgroup of trapezium with 3 spires. Ergonomic and dynamometric jig to implant the trapezium cup has been invented to avoid fracture during implantation.

Clinical study: 58 trapezium cup have been implanted in 6 months with evaluation of the position of the implant in the center of the trapezium.

Résultats: Best bone stock was identified on medial border of trapezium. Only 1/5 trapezium cup with 5 spires was extracted (120N). In the subgroup of trapezium with 3 spires, if only 2 spires were screwed (first serie of test) the extraction load reached 103, 24N (57–133). If 3 spires were screwed (second serie of test) the extraction load reached 89,5 N (45–137). Trapezium was stronger in male than in female No trapezium fracture have been pointed, but slight fissuration of the lateral border were observed in 4 cases after é series of test. The multicenter study allowed to validate the the operative technique of implantation: key point were reported as: optimal view on the borders of the trapezium, implantation of a pin in the center of the trapezium under Xray control and preparation of the bone with approproate jig around the well positionned pin. 2 fractures of the trapezium were observed explained by the implantation of the trapezium cup without help of the Xray control. Each time the surgeon has pinned with no fluoroscopic assistance, the pin was never in the center of the trapezium.

Discussion: The two main complication of trapezio metacarpal prosthesis remain the instability with dislocation and loosening. Such implant is not recommended if trapezium is less than 8 mm. The key point of such procedure remain the implantation of the cup in the trapezium. Bone stock is more important on medial side and implantation of the cup in the center of the bone needs fluorocopic even if the surgeon is an experimented one. 3 spires in the bone of the tested screwed cup remain efficient to reach sufficent extraction load.

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.

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 fixation’s 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.

To determine the functional outcome of floating knee injury a retrospective study was undertaken at 3 level 1 trauma centers.

Methods: Between 1998 and 2004, 96 consecutive patients were identified with at least 2 years follow up. The average age of the cohort is 31 years (15–74) with 76 males. The average ISS was 17.3 (9–57), 31.3% of the patients were multiply injured (ISS > 18). According Fraser’s classification, 78 patients presented a type I lesion. At least one of the fracture was open in 77% of cases.

Results: The preferred fixation method for the femur was IM nailing, either antegrade (58) or retrograde (14). IM nailing of the tibia was performed in 59 cases. Infection occurred at one site in 14 patients and non union in 25. A multivariate analysis did not show any significant increased risk of non union or different clinical result when using a retrograde nailing technique (single knee incision) except a shorter mean operating time (177’ vs. 132’, p=0.0144) and a shorter mean total surgical procedure (155’ vs. 240’, p< 0.0001). The Karlstrom’s score at the latest follow up was obtained in 86 patients (2–4.5 years) and was rated as good or excellent in 63,4% of cases in type 1 injuries versus 16,7% in type 2.

Conclusion: Floating knee injury remain a rare lesion showing extremely bad prognosis factors in general although clinical results remain closely correlated to intra articular involvement at the fracture site.

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.