Purpose of the study: Radiographs of 24 patients who underwent surgery for total hip arthroplasty (THA) with a locked stem were reviewed at 38 months mean follow-up using a dedicated software. This software enables digital analysis of standard radiographs with semiquantitative evaluation of bone density.

Material and method: Good quality postoperative AP views of the femur and the same view at last follow-up were selected using the same criteria. These images were digitalised then analyses with the software. Bone density was established along a horizontal line 1 cm below the lesser trochanter perpendicular to the femur shaft. Computer analysis of bone density established three categories of patients as a function of cortical density: no cortical modification (n=5 hips), modification of only one cortical (n=11) and modification of both corticals (n=8).

Results: Bone density increased, suggesting improve cortical bone stock as has been reported by most authors using the transfemoral approach and a non-cemented locked stem.

Discussion: This result confirms the data in the literature; data which, unlike our series, were established on qualitative or subjective evaluations. The method presented here has the advantage of a semi-quantitative analysis, simple use, applicable to plain x-rays, and good reproducibility since all measures are made by the software. This study demonstrated the notion of cortical quality since it was not limited to a simple measurement of width, but also bone density, closer to real intraoperative observations.

Conclusion: Use of this method enables longitudinal study to establish the kinetics of bone remodelling, compare results between surgical methods, and search for factors explaining observed variations.

Purpose of the study: We report our experience with 59 cases of secondary nailing after external fixation of tibial fractures.

Material and methods: Between 1988 and 2002, 59 tibial fractures (58 patients) were treated initially by external fixation then by secondary nailing. The AO classification was: A (n=28), B (n=20), C (n=11). The Gustilo classification was: closed (n=28), grade 1 (n=18), grade 2 (n=10), grade 3A (n=1), grade 3C (n=2). Tibiotibial or tibio-calcaneal external fixation was used initially for these lower diaphysometaphyseal fractures. The reason for using external fixation was: soft tissue damage (n=38), complex fracture (n=14), associated injuries (n=7). Associated plastic surgery procedures were: medial gastrocnemius flap (n=1), skin graft (n=3). Secondary nailing was undertaken early in 41 cases at about the sixth week because of improvement in the local or general status. For seven cases, the secondary nailing was performed at about four weeks after the multiple-fragment fracture had partially consolidated. There were three infectious complications after nailing (abscess on screw, fistula, pandiaphysistis) in patients whose initial samples of the reaming material were bacteriologically negative. Bone healing was achieved after nailing in 56 cases. Dynamizing the nail was sufficient to achieve healing in one case. Two cases of septic non-union were nailed again and finally healed. The case of pandiaphysitis was treated by removing the nail then a new external fixation which was successful in achieving bone healing.

Results: The results of the secondary centromedullary nailing were satisfactory. Several operations were necessary however (removal of the fixator, nailing, dynaiztion, material removal) with considerable risk of infection. This two-stge method enables treatment of difficult situations rapidly (external fixation) and early (four weeks) revision to allow «programmed» treatment in safer conditions. This secondary nailing can also be used as a treatment in the event of late healing after initial external fixation. Contraindications are pin tract osteitis and serious local infection during the external fixation phase.

Purpose: During surgery for repair of rotator cuff tears, some authors always associate tenotomy-tenodesis of the long head of the brachial biceps. Others decide as a function of the gross aspect of the tendon and its position in relation to the bicipital groove. It is a classical notion the preservation of the long head of the brachial biceps is a cuase of persistent pain in operated shoulders. This study was conducted to search for a histological validation of the decision to perform tenotomy.

Material and methods: Fifty tendons of the long head of the brachial biceps presented a thick and inflammatory aspect with or without subluxation during 68 procedures to repair recent rotator cuff tears (23 men, 27 women, mean age 53.5 years). Tenodesis of the long head of the brachial biceps was associated with proximal tenotomy. The histological examination concerned the most proximal centimeter of the tendon. Four parameters were studied: two concerned the tendon (organisation of the collagen network and aspect of the interstitial connective tissue), two concerned the synovial border (sub-synoviocytic layer and synovial mesothelium). Sixteen tendons which appeared perfectly healthy were harvested from cadaver shoulders to determine the normal aspect of histological parameters (parallel and cohesive orientation of the collagen network, absence of hypertrophic interstitial connective tissue, thin subsynovio-cytic layer and pluristratified synovial mesothelium).

Results: The tendon. The collagen bundles were oriented in 32 cases but thick in 40 and dissociated in 47. Microscopic signs of fissuration or intratendinous tears were present in 17 cases. The tendinous connective tissue was oedematous in 49 cases, presenting fibroblastic hyper-cellularity in 37 and hypervascularity in 43. Scar-like fibrosis was observed in 28 cases. The synovial layer was regular in 11 tendons and clearly thickened in 26 with a mixed irregular aspect in the others. The subsynoviocytic layer was thick in 33 tendons with signs of hypervascularity or hypercellularity in 12. The synovial mesothelium was paucistratifed in 23 cases, thick in 12, and regular in 15. Lesions had an inflammatory aspect and were intense in 26 cases. Degenerative lesions were observed in 21 tendons. These four histological parameters demonstrated that the lesions were advanced and associated with degenerative sclerosis with reactional synovitis in 30 cases, moderate combined lesions in 13, tendon and synovial inflammation alone in four, and advanced degenerative lesions of the tendon and the synovial in six.

Discussion: Histological lesions of the long head of the brachial biceps tendon are generally degenerative and irreversible while most synovial lesions are reversible inflammatory reactions. The zones of intratendinous fibrosis, vascularity and weak or absent cellularity constitute the anatomic conditions before tendon tears in chronic tendinopathy. This histological study confirmed the validity of the intra-operative decision for tenodesistenotomy of the long head of the brachial biceps in 46 (92%) of the cases. The oedematous and fissu-rated aspect of the tendon appeared to be a reliable criteria while inflammatory synovitis, which surrounds the tendon, does not constitute in itself a formal argument in favour of tendon sacrifice.

Purpose: The radial nerve raises several problems during plate fixation of the mid third of the humerus because of its particular anatomic position. Translocation of the radial nerve has been proposed to distend the nerve. There have been few studies studying the feasibility of translocation. The purpose of our work was to validate the translocation effect on nerve distension and the status of the translocated radial nerve branches.

Materials and methods: We report an anatomic study of six cases. These patients had recent communitive fractures of the mid third of the humerus with immediate radial paralysis in three cases. The anterolateral approach was used to expose the nerves that were found to be continuous. Nerve translocation then plate fixation were achieved without neurolysis. The anatomic study was conducted on 15 cadavers: the distance between the last branch for the triceps and the first epicondylar motor branch was calculated in three positions: D0: mean distance in the anatomic position of the nerve; D1: mean distance of the nerve in the anatomic position with the plate; D2: mean distance after anterior translocation of the nerve. We provoked shaft fractures in the mid and lower third of the humerus and evaluated the sensorial and motor branches after translocation.

Results: In this clinical series, translocation was easily achieved in all cases without stretching the sensorial or motor branches. The three radial paralyses recovered in six months. There was not postoperative paralysis for the other cases. For the anatomy study, mean measurements for D0, D1, and D2 were 112, 116 and 106 mm, for a 10 mm gain between D2 and D1. The sensorial branch was stretched making the technique difficult in one case.

Discussion: The results of these two studies confirm the effect of radial nerve distension that facilitates fixation. It frees the posterior aspect of the humerus allowing access in case of nonunion. However, the translocation should be done without neurolysis of the radial nerve and after informed consent from the patient.

Conclusion: Anteromedial translocation of the radial nerve appears to be useful for fractures of the humerus. The ideal indication is an oblique fracture of the mid or lower third of the humeral shaft with immediate radial palsy. A certain degree of comminution facilitates the translocation.

Purpose of the study: A clinical trial on the treatment of humeral shaft nonunions with locked nailing evidenced 5 failures among 13 cases. The circumstances leading to the nonunion, the patient’s condition, and the nailing method were not found to have a predominant effect explaining this outcome. Inversely, clinical data suggested that abnormal mobility of the nonunion appeared to result from play in the assembly. To check this hypothesis, we measured primary stability in three nailing models using cadaver bones.

Materials and methods: Three nailing models, Seidel (S), Russel-Taylor (RT) and ACE were tested, each on 5 cadaver specimens. A 1 cm segmental resection was made in the mid third of the humerus to simulate an unstable nonunion. The nailing was performed in accordance with the instructions furnished by the manufacturers. The nailed specimens were placed in a testing device which alternatively applied a rotation force around the longitudinal axis (± 0.5 Nm), an axial compression-traction force (± 20 N) and a transverse shear force applied at the level of the osteotomy (± 20 N).

Results: This study demonstrated an instability of the three nails when submitted to a rotation force or a shear force: 14 to 28° and 1.6 to 3.4 mm respectively for the RT nail; 8 to 20° and 1 to 3 mm for the S nail; 5 to 15° and 1.7 to 3.2 mm for the ACE nail. The ACE nail appeared to be more stable when submitted to compression-traction force; the S nail accepted a 0.05 to 0.65 mm play which reached 9.7 mm for the RT nail. This instability appeared to result from play in the locking systems.

Discussion: These findings would demonstrate that these nailing systems cannot, in themselves, provide satisfactory primary stability. The experimentally evidenced instability would contribute, probably in association with locally unfavorable physiological or biological conditions, to the failure rate observed when nailing is used alone.

Conclusion: The locking system for tested nails would have to be modified to eliminate play in the assembly before continuing their use for the treatment nonunion of the humeral shaft.