Purpose: A new locked nail is proposed for the treatment of proximal fractures of the humerus. This simple system with self-locking screws was designed for all types of proximal fractures. The purpose of this prospective study was to determine indications and identify limitations.

Material and methods: We used the proposed fixation method sparing the cuff muscles and using a cup-and-ball technique for complex three or four-fragment fractures with major displacement. All nails were locked proximally, with at least two screws, and distally. Early joint mobilisation recommended for this type of osteo-synthesis was applied diversely. This series included 50 fractures of the upper humerus which were all treated with a Telegraph nail between January 2000 and January 2002. We identified 18 fractures of the surgical neck and 32 cephalotuberosity fractures. Mean age was 67 years, range 23–94 years.

Results: The Constant score at maximum follow-up of 24 months was used to assess clinical outcome. Bone healing was effective in all cases but there were several complications: secondary displacement (n=3), fracture of proximal screws (n=5), nail ascension (n=3), rupture of the long head of the biceps (n=1), and stiffness at flexion (n=12), which required removal of the implant in five patients and prosthetic replacement in one.

Discussion: The self-locking screws used with this nail provide excellent stability. Despite the rigid assembly, we observed displacements which led to screw failure and tilting heads. The distal locking screw appears to play a deleterious role in impaction of the fracture. The high rate of complications, 26% in this series, has led to reconsider using plate fixation for complex fractures in young patients and ascending pinning with the Apprill or Hackethal method to avoid aggression on the rotator cuff for fractures of the surgical neck. The Telegraph nail thus does not appear to be indicated only for complex fractures of osteoporotic bone; arthroplasty should be retained for this indication.

Purpose: Fracture of the neck of the femur in elderly subjects is generally treated by arthroplasty, either using a total or intermediary hip prosthesis, but with a high risk of dislocation, estimated at about 10% in the literature. We investigated the contribution of a double mobile cup to lower this risk.

Material and methods: This prospective study was conducted by several operators in the same university unit between 1998 and 2001. A total of 177 mobile prostheses were implanted in patients with fracture of the anatomic neck of the femur (n=145), the neck and trochanter (n=22), or pathologic fracture (n=4). For six patients, the prosthesis was implanted after failed osteosynthesis of a trochanteric fracture. The postero-lateral approach was used for 136 women and 41 men (age range 61 – 92 years) living at home (n=124), or in an institution with a high degree of independence (n=53). The femoral stem was cemented (n=115) or impacted (n=62). A double mobile cup was used in all cases. A chromium-cobalt/ polyethylene couple was used and head diameters were 28 mm (n=150) or 22.2 mm (n=27). We studied outcome and risk of dislocation one year after implantation.

Results: There were six deaths during the postoperative period. Among the 171 patients, 134 were seen at two months, 108 at six months and 89 at one year: 39 were questioned to ascertain outcome. During the first postoperative year, there were 37 deaths; these patients were followed. Six patients were lost to follow-up. We had two cases of intraprosthetic dislocation related to a defect in the chromium-cobalt head retention of the polyethylene insert. These two cases required revision and were reported to material surveillance with corrective measures for the manufacturer.

There were three true dislocations (2%): 1) a posterior dislocation on day 24 in a female patient presenting a fracture with impaction of the femoral stem; 2) a posterior dislocation on day 22 in a female patient in very poor general condition (severe cardiorespiratory failure, death at 48 hr); 3) one recurrent posterior dislocation related to major acetabular retroversion, revised at four months.

Discussion and conclusion: The double-mobile cup appears to be a simple reproducible method for preventing dislocation of prostheses implanted for fracture of the neck of the femur.