Introduction: diaphyseal bone defect is one of the most difficult challenge in Orthopaedic and Traumatologic Surgery. One of the techniques for reconstruction of bone defect described by Masquelet is a two-stage procedure: induction of a membrane around a ciment spacer and autologous cancellous bone graft with external fixator. The aim of the study is to evaluate a modified technique with intramedullary nailing for tibial bone defect.

Materials and Methods: between 2001 and 2006, 13 patients presented important tibial bone defect. On radiological examination, the mean size was 18,5 cm³ (12–30 cm³). Initially, there were 12 opened fractures (1 Gustilo 1, 2 Gustilo II, 9 fractures Gustilo III), and one osteomyelitis following a compartment syndrome. The mean age of the patients at the procedure was 41 years old (18–74). Our modified technique was as follows:

several debridment and stabilization of bone fragments with a temporary external fixator

10 patients had hyperbare oxygenotherapy. All patients were evaluated radiographically and by physical examination. using SF-36 questionnary.

Results: There was no amputation but 4 complications. There were 3 deep infections: one just between the 2 stages and one 2 years after the second stage: both were treated by nail exchange and adapted intra-venous anti-biotherapy. The third one was the complete bone graft resorption because of an infection just after the second stage (the only failure of the method). The fourth complication is the nonunion 13 months after the second stage: nails has broken and has been changed. Bone healing was obtained in 12 patients at mean follow-up was 32 months (12–69). They were able to walk 4,3 months after bone grafting. 8 patients answered to the SF-36 questionnary: overall function was limited with a mean score of 99.8.

Discussion: and conclusion: Our modified technique gave satisfactory results at medium term. Nailing, comparing to external fixator, offers a better stabilization of bone fragments, better control of axis and length of lower limb, and an easier access for plastic surgery and nurse care. Others bone reconstruction treatment like ilizarov bone transport, free vascularized fibula fiap or allograft are still possible if failure. However, the rate of deep infections are quite high (4/13) may be questionable. Sacrifice of intramedullary blood supply and the difficulties to confirm union on radiological exams are still problematics.

Introduction: The conventional treatment of humeral shaft nonunion is plating and cancellous bone grafting. This option is very efficient but not absolutly safe. In case of initial treatment by nailing, a secondary compression at the site of the fracture could be an alternative.

Materials and Method: Between January 2000 and december 2003, in a prospective study, 56 patients have been operated for an acute humeral shaft fracture using retrograde locking nailing (UHN^®, Synthes™). 4 patients (7%) had an aseptic and tight nonunion. All of them were treated by secondary closed compression without bone graft. The mean age of the patients was 42 years-old at the procedure (range 17 to 73). All the patients were reviewed with clinical and radiological exams, using the DASH and Rommens scores and standard radiographs.

Results: No per or post operative complication occurred. Bone healing was obtained in all cases within 4 months. At an average follow-up of 66 months (range 51 to 74), the average DASH score was 29.6/100 (range 8.3 to 60.8) and the Rommens score was excellent in 3 patients and moderate in one because of history of Complex Regional Pain Syndrome.

Discussion and Conclusion: One of the characteristics of the retrograde nailing with UHN is to permit an initial or secondary axial compression at the site of the fracture. Secondary compression in the treatment of non union offers the advantages of a closed procedure which avoids any radial nerve injury, and preserves the bone vascular supply. In the present preliminary series, the isolated secondary compression appeared as a simple and safe procedure which allowed bone healing in all cases.

MATERIAL AND METHODS. From 1986 to 2002, among 195 fractures treated with this plate, 181 were evaluated. A first series of 116 cases analysed in 1997 (follow up 22 months) was enlarged by a recent series of 65 cases (follow up 29 months). According to Duparc, there were 5(2.7%) type II, 69(36.9%) type III, 103(55.1%) type IV, 10(5.3%) type V. According to Sanders there were 67(37%) type 2, 65(36.9%) type 3, 49(27.1%) type 4. The protocol was as follows: fractures were investigated with standard views (including Broden’s views) and CT scans. The average delay before surgery was 5.5 days. Blisters were not a contraindication to surgery, if not obviously infected.

Reduction was performed by an extended lateral approach, and checked under fluoroscopy. Joint reduction was fixed by screws. The reconstruction plate, bent in a standard way, was then placed laterally, from above the tuberosity towards the inferolateral part of the anterior process. All but one or two posterior screws ideally converge to the sustentaculum tali (ST), building a strong support below the posterior facet. Postoperatively partial weight bearing below the threshold of pain was allowed in the majority of cases. Clinical results were assessed using the French Orthopaedic Society (SOFCOT) functional score for both series, and AOFAS (American Foot and Ankle Society) score, and Mary-land Foot Score (MFS) for the recent series.

RESULTS. According to the SOFCOT, there were 74% good and excellent results. The average MFS was 87/100, the average AOFAS score, 82/100. The average beginning of walking without crutches was 10 weeks. In the second series of 65 cases, 78.4% of active patients went back to their previous job at the same level.

Reduction was assessed anatomic on the postoperative Broden view in 90.5% of cases. The average Böhler’s angle remained stable. Secondary fusion of the subtalar joint was required only in 4 cases (2.1%). Wound healing was delayed in 19.7%, but generally, it was spontaneously obtained in a few weeks. Three deep late infections (1.6%) healed after plate removal.

DISCUSSION. ORIF of displaced articular calcaneal fractures using a contoured lateral plate has yet become a routine in our institution. The concept of screws converging from the plate to the ST, which is the strongest part of the broken bone, provides both optimal fixation of the primary fracture line (separation fracture), and a solid support below the reduced posterior facet. In most of cases early partial weight bearing did not jeopardize articular reduction, except the 4 (2.2%) significant secondary displacements. Therefore, in very comminuted fractures involving the tuberosity, we rather use of the new AO locked Plate.

Conclusion: Because the reconstruction plate was always modelled in the same standardized shape, we developed a specific precontoured thinner plate.

Purpose of the study: Locked plating is an attractive alternative to external fixation for the fixation of distal shaft fractures of the radius, particularly in cases with metaphyseal comminution. The purpose of this study was to assess prospectively outcome with locked anterior plate fixation in a series of 43 complex fractures of the distal radius treated between October 2003 and November 2004.

Material and methods: The AO LCP 3.5 plate (Synthes) was used. The series included 27 women and 15 men, mean age 55.5 years (range 17–83 years). We included fractures with major metaphyseal comminution according to the M.E.C classification established by Laulan (18 M2, 14 M3, and 9 M4). According to the AO classification, there were nine extra-articular fractures (eight A3 and one A2) and 35 articular fractures (ten B3, two C1, four C2, and seventeen C3). Posterior displacement was noted for 22 fractures. In eight cases plate fixation was a second intention procedure due to secondary displacement occurring on average eight days (range 3–21 days) after trauma for a fracture initially treated with infrafocal pinning. An epiphyseal locking screw was used in all cases. An antebrachiopalmar immobilization orthesis was worn for six weeks on average (range 3–9 weeks). The first-intention anterior plating was combined with an intrafocal posterior pin for 13 patients and with an external fixator in one. Radiographic outcome was reported in terms of joint congruency and using the SOFCOT symposium criteria for the 41 patients reviewed at bone healing.

Results: Anatomic restitution was achieved in 23 patients (55%). There were two purely intra-articular calluses due to failure of the primary reduction, both measured less than 2 mm. Fifteen moderate misalignements (36%) were noted, most (84.7%) involving moderate sagittal inclination, the distal radioulnar index being preserved. Two major misalignments (5%) were related to early disassembly of the osteosynthesis.

Conclusion: Locked anterior plating has provided promising results for maintaining radial length in distal radial fractures with major metaphyseal comminution. There remains a certain number of cases with a moderate and persistent posterior inclination and a few cases of defective intra-articular reduction.

Aim: The operative management of proximal humerus fractures is still viewed as an unsolved question.

Surgical treatment aims at restoring anatomical elements to a condition stable enough, to allow early mobilization to avoid secondary displacement. The blood supply of the humeral head should not be damaged, so the risk of avascular necrosis will be minimal.

This work offers a new surgical technique that dramatically reduces the need for dissection of soft tissues while using a new locked plate.

Material and Method: This prospective study was carried out between August 2002 and March 2004. 47 fractures of the humerus proximal were operated on 47 patients aged 63 as an average. There were 9 four part fractures, 18 three part and 17 two part fractures.

The two arms of this Y shaped plate embrace the humeral head. The anterior arm overbridges the biceps longus tendon and fixes the lesser tuberosity, with a locked screw in the head. The posterior arm fixes the greater tuberosity with an another locked screw. These two screws cross each other at nearly right angle thus giving optimal fixation in the head.

Results: Fourty four patients (44 shoulders) were later re-examined with 10,3 months mean delay. Re-education was made immediate for 85% of the cases. The final evaluation was made with the functional Constant score and X ray control.

The main complications were 3 algodystrophies, 1 hematoma, 4 failures of fixation, 2 nonunions and only one necrosis.

Conclusion: This first clinical experience with this new implant is stimulating, since it provides a reliable fixation, even into the osteopenic bone.

Purpose: We report our first cases of retrograde nailing using the universal humerus nail (UHN).

Material and methods: Fifty patients (26 men and 24 women), mean age 60.2 years, with fracture of the humerus were treated with the UHN; most had shaft fractures, 40 were trauma victims, and ten had metastases.

Retrograde nailing was achieved by trepanation of the apex of the olecranon fossa. Proximal or distal locking was applied in all cases using one or more screws. Outcome was assessed with the S.O.O. criteria (1996).

Results: Two patients were lost to follow-up and two patients died early. Forty-six patients were reviewed with a mean follow-up of six months (range 3–18). Outcome was very good or good in 43 patients (bone healing at three months), fair in one, poor in two (two constructs dismounted at day 15); three asymptomatic fractures did not heal at one year (all healed two months after compression). Peroperative complications included: four fissures of the posterior cortical at the entry window and two supracondylar fractures. One patient developed radial palsy in the immediate postoperative period that resolved spontaneously. One of the proximal locking screws loosened early in four patients. Finally, one patient developed a supracondylar fracture at the point of entry following a fall four months after the nailed fracture had healed.

Discussion: The two cases of dismounting were subtuberosity fractures in elderly patients; likewise the one fair outcome was a minimal secondary displacement that had not healed at five months. The proximal locking screws did not hold well in osteoporotic heads explaining the three cases of early screw loosening. Impacting the curved nail into the last centimeters is a delicate operation and we had two fissures of the posterior cortical and peroperative supracondylar fractures early in our experience. Finally, the absence of an aiming device for the proximal locking screw complicates this procedure. The possibility for orthogonal proximal locking is however an advantage for rotatory stability. This nail allows early rehabilitation without mobilisation.

Conclusion: Retrograde locked nailing provides good results at three months for humeral shaft fractures. Subtuberosity fractures in elderly patients are not good indications. A straight nail would however be preferable and an aiming device for the proximal locking would be useful.

Purpose: We wanted to ascertain whether the advantages of functional treatment on trophicity could be combined with the advantages of surgical treatment on anatomic results in patients with displaced calcaneal join fractures.

Material and methods: Using the AO 3.5 reconstruction plates with specific stereotypic modelling we were able to obtain solid fixation in almost all cases of calcaneal joint fractures using a rigorous technique and following precise principles, notably the direction of the screw into the sustentaculum tali.As the osteosynthesis is very stable, we postulate that partial and progressive early weight bearing would be acceptable as long as pain was under a threshold level used as sign of micromobility. The first cases were very favourable so we extended this method, using it as a routine procedure for all cases (excepting those with an associated injury excluding weight bearing). Among 122 fractures operated with this method, 118 were reviewed.

Results: According to the Duparc classification, we treated one type 2, 34 type 3, 76 type 4 and seven type 5 fractures. Weight bearing was initiated on the average at 14 days, with a median of seven days. The Boehler angle improved from 0° preoperatively to 22° postoperatively. We did not have any cases of secondary displacement greater than 2°. The functional outcome was, according to the SOFCOT criteria: very good 34.5%, good 41.4%, fair 9.5% and poor 0%. Physical results (SOFCOT criteria) were: very good 17.2%, good 54.3%, fair 26.7%, poor 1.7%. Anatomic results according to AFC criteria were: very good and good 69%, fair 25.9%, poor 5.1%.

Discussion: These result demonstrate that a rigorous therapeutic management scheme can combine the advantages of functional and surgical treatment of displaced calcaneal joint fractures. Early weight-bearing below the pain threshold was effective since all our bilateral cases could be discharged after walking a few steps. Recovery was more rapid when weight bearing was late. Crutches could be abandoned at two months on the average.

Conclusion: We believe that solid osteosynthesis is possible in almost all cases of displaced calcaneal fractures with joint involvement if a rigorous technique is used. Progressive early weight bearing below the pain threshold is a significant adjuvant factor favouring rapid and quality outcome.