Purpose: Management of supracondylar fractures of the humerus becomes a controversial issue when there is major displacement. The risk of vessel and nerve injury is very high, making reduction and fixation particularly difficult.

Material and methods: We conducted a retrospective analysis of 100 supracondylar fractures managed over a ten year period. All of these fractures were in extension and exhibited a bone gap. We analysed early and late complications.

Results and discussion: Mean age at trauma was 6.5 years, with six boys for four girls. The left side was involved in 69% of the cases. Falls were the predominant cause (48%).

Thirty-two percent of fractures were complicated initially: nerve injury (n=17), vascular injury (n=12) (including three cases with nerve and vascular injury), open fractures (n=7). The medial nerve was injured in most cases (n=12). Ulnar palsy was noted in four patients and radial palsy in one. Vessel injury led to abolition of the radial pulse in eight patients and the ulnar pulse in one; all resolved after reduction. Ischaemia of the hand was noted in two cases before reduction of the fracture but vascular surgery was not required.

Most of the fixations were achieved with cross pinning (percutaneous insertion in 47 patients and open surgery in 13). Despite minimal medial skin incision, ulnar nerve deficiency was observed after surgery in seven cases; four were rapidly regressive and three required surgical exploration with neurolysis. Six revision procedures were required for secondary displacement (10%).

The 26 Judet fixations led to ten secondary displacements requiring surgical revision for cross pinning. Four cases of postoperative ulnar nerve deficiency were noted: reoperation to release the nerve pinched in the fracture was required for only one patient.

The Blount technique was used in nine cases with four secondary displacements, including one related to two sites of nerve impingement.

Five cases of superficial pin tract infection which resolved rapidly and two cases of deep infection were noted in the early postoperative period.

Formation of a varus ulnar callus was noted in five cases: two required secondary surgery for correction.

Conclusion: Our results point out the high rate of vessel and nerve complications related to these supracondylar fractures of the humerus with displacement. We recommend cross pinning which is mechanically superior and which does not compromise the neurological result if a minimal medial incision is used.

Purpose: We analysed knee prostheses preserving the posterior cruciate ligament (or both cruciates) performed after tibial osteotomy. We determined outcome as a function of any tibial callus deformation created by the tibial osteotomy.

Material and methods: This retrospective study included a consecutive series of 56 knee prostheses with preservation of the posterior cruciate ligament (n=43) or both cruciate ligaments (n=13). The patients had undergone prior tibial osteotomy for valgisation (n=47) or varisation (n=9). Seven groups were defined as a function of the preoperative tibial angle prior to TKA. The angle were measured with telegonometry. Minimum follow-up was one year, mean follow-up 4.1±2.8 years.

Results: The tibial tuberosity was raised in 15 cases. If there was major valgus or rotation deformation, tibial osteotomy was associated with the prothesis (n=9). At last follow-up, the mean IKSg, IKSf and HSS scores were 81.5, 77.6, and 82.3 respectively. The mean femorotibial angle was 177.4±4.2°. The mean tibial angle was 87.8±3° and the mean femoral angle was 89.8±2°. Preoperative tibial deformation was not influenced by clinical results. In case of preoperative tibial deformation situated between 5° valgus and 5° varus, operation time, blood loss, and femoraotibial axis at last follow-up were not significantly different. To correct for tibial valgus greater than 7°, tibial osteotomy was associated with prosthesis implantation during the same operative time in six out of thirteen cases. For preoperative tibial varus greater than 5°, the femorotibial axis was less well corrected.

Discussion: These clinical results were comparable to those reported in other series with preservation or not of the posterior cruciate ligament. Correction of the femorotibial angle was less satisfactory than in certain series, but the deformation and the surgical history were among the most marked in the literature. Preservation of the posterior cruciate ligament (or both cruciates) appears to have increased the technical difficulties for upper tibia exposure and position of the tibia implant. For tibial callus with valgus greater than 7°, the prostheses cannot be expected to provide a solution alone and osteotomy should be associated. For tibial callus with 5° or more varus, the indication for associated tibial osteotomy merits discussion.

Purpose: There are three main causes of failure after valgisation osteotomy of the tibia requiring repeated osteotomies: insufficient valgus, excessive valgus, or loss of the valisation correction after a variable delay. The purpose of this study was to evaluate outcome after repeated oseotomies performed in relatively young patients or too active to propose arthroplasty. The technical problems were different for each aetiology.

Material and methods: The series included 47 knees operated on between 1974 and 1998 after a first osteotomy performed at a mean age of 46 years. Mean delay between the two operations was five years (1 to 12). A medial closure osteotomy had been performed at the first operation in 34 cases and a lateral opening osteotomy in 13. For the 19 knees with valgus, the second osteotomy was a medial closure in 14 and a lateral opening in five. A repeat valgisation was performed in 28 cases, 18 by lateral closure, one by medial opening and nine by curviplanar osteotomy. The IKS score was determined to assess function. The femoraotibial axes (HKA angle) were determined on full stance views. The Ahl-back osteoarthritis grading was used. For 17 patients who had undergone operations in other institutions, exact measurements were not always available concerning the preoperative status and the initial correction.

Results: The overall IKS score for function improved in 87% of the cases with a mean follow-up of five years. The IKS knee score improved from 73 to 89 points and the IKS function score from 65 to 81 points. For the 19 over-corrections, the mean HKA angle was changed from 190° to 184°. For the 28 under-corrections, the mean HKA angle was changed from 173° to 182°. The tibial tilt remained unchanged at 7° as did lateral gapping at 3°. Delay to consolidation was a mean 96 days.

Discussion: Revision osteotomies performed for correction defects should be distinguished. For these procedures, it would be logical to expect a good result if a 3 to 5 degree valgus is achieved. Revisions after a long period (33 cases) are different; required for wear, these cases correspond to progressive loss of the initial osteotomy effect. These patients are often candidates for prosthesis if seen after 70 years. Good results can however be obtained with a second osteotomy irrespective of the initial technique. We prefer reoperating with medial opening after initial lateral closure.