Introduction

Osteoporosis is a metabolic disease of the bone responsible for a loss of bone resistance and an increase in fracture risk. World Health Organization (WHO) estimations are about 6.3 millions of femoral neck fractures in the world by 2050. These estimations make osteoporosis a real problem in term of public health.

Knowledge in biological tissues mechanical behaviour and its evolution with age are important for the design of diagnosis and therapeutic tools. From the mechanical aspect, bone resistance is dependent on bone density, bone architecture and bone tissue quality. If the importance of bone density and bone architecture has been well explored, the bone tissue quality still remains unstudied because of the lack of biomechanical tools suitable for testing bone at this microscopic dimension.

Therefore the goal of this study is to estimate the osteoporotic cancellous bone tissue mechanical behaviour at its microscopic scale, using an approach coupling mechanical assays and digital reconstruction.

Purpose of the study: Classically, bone grafts are harvested from the iliac crests which can provide a limited volume of graft material. Using the reaming product might help spare iliac bone.

Material and method: A variable head RIA device (reaming, irrigation, aspiration) was used over the last year for ten patients who presented partial or segmental bone loss. The bone graft was constructed exclusively with the reaming produce following membrane induction using a cement scaffold. The tibia was reconstructed in nine cases and the humerus in one. Bone loss was 6 cm on average.

Results: The reconstruction healed in six cases within a mean delay of 6 months; the 4 other cases are under assessment. Complementary bone was necessary to achieve healing in one case. There were no complications involving the donor site excepting transient pain at the point of insertion.

Discussion: In this series associating an induced membrane and reaming produce, the time to healing appeared to be shorter than with cancellous iliac bone. The smaller size of the fragment may be a determining factor.

Conclusion: Reaming products collected from medullary cavities of the long bones can be used for reconstruction of bone loss.

Purpose: The diversity of treatments proposed for septic nonunion of the femur demonstrates the lack of consensus. Treatment modalities validated for the leg appear to be transposable to the femur. The purpose of this work was to compare different treatments used in our centre and identify optimal management practices.

Material and methods: We report a retrospective series of eleven patients (nine men and two women) who developed septic nonunion of the femur subsequent to trauma (n=9) or tumour (n=2). Sepsis developed early in seven cases and late in four. Mean time to treatment was 34.8 months. We based our strategy on a succession of steps starting with cure of the soft tissue and bone infection, before attempting reconstruction and consolidation.The first step involved fixation, antibiotic therapy and interposition of an acrylic spacer. The second step involved bone reconstruction, removal of the spacer, vascularised fibular graft associated with a cancellous bone graft (n=4) or massive cancellous graft inserted into the pseudomembrane created by the spacer (n=7).

Results: Mean time to resolution of the infection was 10.9 months. Cure could not be achieved in three patients. Bone continuity was achieved in 8.8 months on average. The time to bone healing (i.e. duration of external fixation) was 22 months. Refracture occurred in four patients. Consolidation was not achieved in two patients.

Discussion: During the second step, we preferred massive cancellous bone reconstruction due to easier technique, shorter healing time, and better adaptation of the reconstruction volume. Optimal time for the first step is about six months in order to avoid recurrent infection. Our healing times are similar to those reported by others: the healing index (time to healing divided by gap length) was close to that obtained with the compression-distraction technique. Refractures related to specific mechanical problems inherent in the femur lead to longer time for external fixation, minimum 13 months.

Purpose: Instability of the injured elbow early after repair can lead to recurrent dislocation or failed fixation. Complementary immobilisation increases the risk of stiffness. The purpose of this study was to assess the contribution of dynamic external fixation which allows protected mobilisation and controlled distraction. We wanted to determine feasibility and appropriate indications.

Material and methods: We used the Pennig articulated elbow fixator in twelve trauma victims. Most had complex injuries: five dislocations with lesions of the medial ligaments and fractures of the radial head, including two with early recurrent dislocation; five joint fractures (involving to various degrees the lateral condyle, the head of the radius, the olecranon, and the humeral surface). This fixation method was also used for old or sequelar lesions to achieve reconstruction of the humeral surface (n=3) or after extensive arthrolysis (n=2). Mobilisation was started on day five postop.

Results: For the fresh injuries, the humero-ulnar articulation was centred in all cases. In these patients, mean final flexion was 0.35.130° and pronation-supination was 0.10.155°. One purely lateral dislocation was observed. Radio-ulnar synostosis after fracture of the ulna (n=1) and osteoma (n=1) were also observed.

Discussion: This dynamic external fixation system is a simple and safe procedure if a rigorous technique is applied. This method enabled early rehabilitation without secondary displacement and also enabled reliable contention particularly important in these multiple injury patients. The patients experienced very little pain during rehabilitation exercises, probably due to the distraction which did not appear to provoke reflex dystrophy. For complex instability of the elbow, the reduction of stress forces during mobilisation movements enables an extension of the indications for preservation of the joint fragments. Less reliable results are obtained for stiff elbows with old lesions.

Purpose: Bone quality in elderly patients always subject to osteoporosis can compromise the stability of osteosynthesis materials. The fixation can be reinforced by using acrylic cement, allowing early rehabilitation. The purpose of the present work was to investigate the quality of acrylic cement-reinforced osteosyntheses and to study the functional consequences of this method. We also analysed early or secondary complications and determined the mid- and long-term advantages and disadvantages for the patient’s quality of life and also for later interventions on the fracture site.

Material and methods: Forty female patients treated between 1990 and 2000 were studied retrospectively. These elderly women (mean age 86.2 years at fracture), had 44 fractures (38 femurs including two with double fractures; four humeri) which had been treated by acrylic cement reinforced ostheosynthesis. The physiological status of the patients before trauma was assessed with the Robinson score and the degree of osteoporosis with the Sinon index. The quality of the cementing was assessed using the Cameron technique. Minimum follow-up was six months, necessary for inclusion.

Results: The preoperative Robinson score was 18.8. The mean Singh index was four. Cementing was satisfactory for 29 fractures. Immediate weight bearing or complete use of the limb was possible early for 42 of the 44 fractures. Bone healing was achieved at a mean 2.8 months for 43 fractures. Mean follow-up was 9.8 months. Twelve patients died before the end of the first postoperative year. At last follow-up, there was one nonunion and five infections, including three bone infections. The Robinson score at last follow-up was 16 on the average. Subsequent interventions did not have to be modified or abandoned because of the acrylic cement reinforcement of the osteosynthesis.

Discussion: The results of this retrospective series are comparable with those obtained with other centromedullary nailing or primary or secondary bone grafting techniques used for the treatment of patients with severe osteoporosis.

Purpose: Reconstruction of massive bone loss with cancellous bone deposited in a pseudomembrane induced by a cemented strut was performed in 40 procedures. We evaluated the 5-year results of this technique for the treatment of gaps measuring more than 5 cm.

Material and methods: We reviewed 12 patients; all had suffered major loss of tibial bone. The operations consisted in resection, insertion of a cement strut, and closure with a local are free flap over he disinfected soft tissues. The second operation at least two years later used a fragmented autologous cancellous graft leaving the membrane intact. The fibula was used as a tutor whenever possible. Bone losses measured 5 to 25 cm in young men who had infection after trauma or, in one patient, tumour resection. We analysed clinical and radiological outcome.

Results: All patients were seen five to ten years after initial management. At last follow-up, all wounds had dried and bone healing was solid. All had required secondary repeated grafts, realignment surgery (for valgus and varus) or operations related to the initial injury (arthrodesis, claw toe). Generally, the patients had resumed their occupational and recreational activities. The walking distance was not limited and single leg stance was painless. The radiological analysis demonstrated a trend towards graft tubulisation.

Discussion: The stut technique using cement induces the formation of a pseudo-synovial membrane. This technique has been used for more than ten years in our unit to treat circumferential defects. Bone healing was achieved in all patients. The main complication was valgus malalignment which almost always requires surgical correction. Rapid healing is not a function of the extent of the gap but rather the radical nature of the resection and the quality of the cover. This technique should be compared with other alternatives used to fill major bone gaps (Illizarov, vascularised bone transfer).

Purpose: Loss of cutaneous tissue during knee prosthesis procedures raises the risk of implant exposure and infection with subsequent removal and poor functional outcome. The clinical course of the tissue loss is unpredictable leading to retarded curative treatment.

Material and methods: We report a consecutive retrospective series of 39 knee prostheses implanted from 1990 to 2000 where cutaneous tissue loss was covered with a flap. We studied time to onset of tissue loss, wound border vitality, presence or absence of implant exposure, type of cover flap distinguishing faciocutaneous and muscle flaps, retention or not of the implant, and time of secondary reconstruction.

Results: In 38 of the 39 prostheses, the implant use of the cover flap enabled saving the implant and proper wound healing. The joint remained functional but only 18 knees recovered flexion greater than 90°. In one case, the implant had to be removed due to infection with resistant Serratia. Prognositic factors identified included: time from tissue loss to its treatment, usefulness of a cover flap to save the implant, or usefulness of two-procedure reconstruction in case of implant infection.

Discussion: We compared our therapeutic methods with the propositions in the Laing classification and preferred to distinguish a simplified three-step tactic based on time of exposure for determining the theraputic strategy for cutaneous tissue loss in knee prosthesis patients.

Purpose: Post-traumatic instability of the elbow is defined as a subluxation of the humeroulnar joint at least three weeks after trauma. Treatment is based on restitution of the three elements essential for stability: the coronoid process, the height of the head of the radius, repair of the lateral ligaments. The purpose of this study was to analyse treatment modalities for these unstable elbows and assess mid-term results.

Material and methods: This consecutive series included all patients who underwent surgery between 1992 and 2000. There were 22 patients (twelve men and ten women, mean age, 46 years, age range 26–74 years). The left elbow was involved in 16 cases (two dominant) and the right elbow in six cases (six dominant). The initial trauma was isolated dislocation in six patients, dislocation with fracture of the coronoid process and the head of the radius in nine, trans-olecranon fracture-dislocation in seven. Mean time from trauma to revision for instability was four months. A dynamic external fixator was used for stabilisation in all cases, with or without restoration of the height of the radius with a radial head prosthesis (n=12), and reconstruction of the coronoid process (n=7). Reinsertion of the lateral ligaments was necessary in 17 patients.

Results: Mean follow-up was 33 months. Six patients required a second procedure for transposition of the ulnar nerve in three and arthrolysis of the elbow joint in three. There was one failure requiring total elbow arthroplasty less than one year after revision. At last follow-up, outcome according to the Mayo Clinic classification was excellent in ten patients, good in five, fair in one, and poor in five (four trans-olecranon fracture-dislocations). Twenty patients had a stable elbow. Mean flexion-extension was 113° with a 19° mean extension deficit. At last follow-up, six patients had radiographic signs of osteoarthritis.

Discussion and conclusion: The results were directly correlated with the nature of the initial trauma and the quality of the restoration of he stabilising elements. The poorest results were observed after trans-olecranon fracture-dislocation, which led to osteoarthritic degradation in three out of four cases. In our experience, treatment of sequelae of elbow dislocation, or the terrible triade, can give satisfactory results with an appropriate treatment strategy.

Purpose: Demonstrate the importance of surgical repair of soft tissue damage in an orthopaedic surgery unit.

Material and methods: This retrospective study included 455 patients who underwent soft tissue flap surgery between April 1980 and April 2000. There were a total of 556 flaps, hand and finger flaps were excluded from the analysis. Overall results concerning the general treatment for the underlying conditions was not analysed. There were 132 women and 313 men, mean age 42 years. Among these patients 276 (60%) were referred from other hospitals for secondary care. Most of the tissue damage (373 patients among the 455) concerned the lower limb. The soft tissue loss was part of a bone and joint problem in most cases, including: septic nonunion and osteitis (189 patients), trauma and complications after planned orthopaedic surgery (74 patients), grade IIB or IIIC open fractures according to the Gustilo classification (66 patients). There were a total of 485 pediculated or fasciocutaneous muscle flaps and 71 free flaps.

Results: Flap survival rate was 90.32%. The result was total necrosis of the flap in 9.68%. The rate of failure was 30% for free flaps and 5% for pediculated flaps.

Discussion: This study demonstrated the usefulness of surgical care of soft tissue damage in an orthopaedic surgery unit, particularly for trauma and infection patients. The large number of pediculated flaps is an expression of the reliability of this technique easily applied in a polyvalent orthopaedics traumatology unit. The high rate of failure for free flaps is related to the inherent risk of secondary repair and the inflammatory or infected nature of the soft tissues and also the difficulty encountered in controlling this type of surgery under such conditions. The data reported here allow individual analysis by type of pathology.

Conclusion: Overall management of bone and joint disease patients requires proper skill in soft tissue repair.