Purpose of the study: Osteosynthesis procedures proposed for fractures of the proximal humerus have evolved greatly since the development of anterograde nailing systems with the objective of providing a conservative surgical solution for sometimes complex fractures. We analyzed retrospectively the results obtained in a consecutive series of 30 patients treated in our unit with a Telegraph® nail.

Material and methods: Between March 2001 and August 2003, 39 patients presenting fractures of the proximal humerus were treated with a Telegraph® nail. Accorrding to the Duparc classification, the fractures were: 17, 11 ST+T, 4 CT II, and 7 CT III. Five patients died before the review presented here. Four CT III fractures presented material disassembly early and required revision with a hemiarthroplasty. For the 30 patients reviewed here, we noted the Constant score and the results of the Matsen test as well as radiographic findings.

Results: Mean follow-up for the 30 patients was 16 months (range 6–33). Mean age at trauma was 58.7 years (range 19–91). The mean Constant score was 57.4 (range 16–84) with 72% after weighting. The Matsen test was positive for 59%. Subjectively, 69% of patients were satisfied or very satisfied. There were several complications: secondary intraoperative shaft fracture treated orthopedically, four nonunions of the surgical neck, four tuberosity migrations, three cases of head necrosis, two subacromial impingements (one with rotator cuff tear). Nonunion was generally observed with static locking and in one case with an oversized nail. We were unable to identify any factor predictive of head necrosis due to the small number of cephalotuberosity fractures. Disassembly was generally observed in patients with an initially displaced fracture with periosteal rupture, osteoporosis and old age.

Discussion and conclusion: Our results are less satisfactory than others published in the literature for series using this material and it is difficult to compare with results for series using other types of material because the study criteria were highly variable. Although all fractures in this series, including the most complex, appear to benefit from this nailing system, we did note that complications were not exceptional even though certain compliations observed were related to our learning curve. Surgeons should be aware that the planned option can be changed intraoperatively. Arthroplasty may be necessary in certain cases if the conditions are not adequate for stable osteosynthesis.

Purpose: We report a series of 50 pilon fractures treated by osteosynthesis and report outcome at minimum seven years.

Material and methods: The series included 28 men and 22 women, mean age 44 years. Thirty-one patients were fall victims. The AO classification was type B (n=24) and type C (n=26). According to the De Lestang classification there were 12 simple fractures and 38 complex fractures (including 26 complete fractures) Sixteen fractures were open and 39 were associated with a fracture of the lateral malleolus. Most of the fixations were achieved via an anterolateral approach (n=22) using a prebent plate, or via a medial approach using a clover-leaf plate. A cancellous graft was used in seven cases. The Kitaoka classification was established at last follow-up.

Results: The radiographic work up included a lateral view and an anteroposterior view with moderate medial rotation. Mean follow-up was fourteen years. There were ten secondary displacements. Late complications were: non-union (n=14, including 10 cases requiring revision for arthrodesis), reflex dystrophy (n=6), deformed callus formation requiring revision, and one case of amputation after infection. At last follow-up, 33 ankles were painful (including 13 permanently painful ankles). Twenty-four patients had a residual limp (13 permanent) limiting walking distance in half of them. The talocrural joint motion was normal in 20 patients and the subtalar joint was normal in 24. Twenty-three patients resumed their former activities. For patients with sports activities, 64% resumed activities at the same level. The Kitaoka score was 79 points at last follow-up with outcome scored good in 70%, fair in 16% and poor in 14%. Excepting the patients who had secondary arthrodesis, 24 patients developed secondary osteoarthritis (including ten stage 2 and 3).

Discussion: Good outcome depends on the intraoperative reduction, both at the epiphyseal level (for complete fractures) and the metaphyseal level. This reduction must be maintained over time with a good fixation rigid enough to avoid secondary displacement which is a cause of callus deformation. The severity and complexity of the initial fracture constitute the main factors affecting outcome. In our opinion, computed tomography provides the best means of establishing the therapeutic indications. Pilon fractures remain a difficult challenge in orthopaedic surgery. Perfect reduction is the best guarantee of good outcome.