Introduction: The three or four-part fracture of the proximal humerus remains a challenging fracture in the case of elderly patient. In this continuing prospective study we compared the outcome after implantation of a shoulder hemiprosthesis of the anatomical generation and a reversed prosthesis.

Material and methods: 34 shoulder prosthesis were implanted in patients older than 70 between june 1996 and june 2004. All patients were evaluated by a surgeon not involved in treatment concerning activities of daily living (DASH scoring), clinical outcome (Constant-Murley Score), radiological results, and a summary of complications.

Group 1: anatomical prosthesis (Tornier): At an average follow-up of 16,5 (range 6–55) months, 13/17 patients with an average age of 78,6 years (70–95), were evaluated.

Group 2: reversed prosthesis (Depuy): At an average follow-up of 12,6 (range 6–18) months, 13/17 patients with an average age of 77,1 years (70–84), were evaluated. In this group functional treatment was started immediately after surgery.

Results: concerning age, follow up and dash scoring there were no difference between two groups. In reversed group : the outcome was better (Constant-Murley: 79,5 (57,8–100) vs 57,1 (21–85) p=0.005), the average active elevation was better by 30° (p< 0.001) and the average active abduction was better by 53° (p< 0.001). 7/13 cases of glenoid notching stage 2 or 3 were noted. In anatomical group : the average active external rotation was better by 10° (p=0.01). Tubercle fixations failed in 6/13 cases.

Discussion: No comparative study has still been published between the two sort of implant in elderly patients. Our results of shoulder arthroplasty in acute injury to the proximal humerus with reversed prosthesis are in agreement with the preliminary results reported by Sirveau. At short follow up, reversed prosthesis allow to reach early mobilisation with best functional results. Rotation remains the key point : with a significant gain in active abduction and elevation the reversed prosthesis group do not reach a better dash scoring. Attachment fixation of the posterior rotator cuff must probably be discussed in reversed prosthesis in acute fracture.

Purpose of the study: Reinsertion of the brachial biceps on the radial tubercle has been an effective method for recovering cyclic supination. Several surgical techniques have been proposed but only one clinical evaluation of operated patients has been published. We report the first study of a clinical and magnetic resonance imaging (MRI) assessment of brachial biceps reinsertion in the anatomic position using an anchorage system. The purpose of this work ws to determine whether the reinserted biceps remains inserted and to analyze the zone of insertion.

Material and methods: Nine manual laborers underwent surgery between 1999 and 2003 for repair of a ruptured brachial biceps by reinsertion on an anchor. The patients were reviewed by an independent operator (measurement of force and flexion). A 3-Tesla MRI machine was used to evaluate the position of the reinserted biceps. Reinsertion was performed within 5 days of injury (range 3–9 days) using the same technique of anchorage in the radial tubercle in all cases. A longitudinal incision measuring 3–5 cm along the medial border of the radial brachial was made to localize the ruptured biceps and the radial tubercle and drill two or three insertion holes for the anchors. The suture threads were used to bring the brachial biceps tendon progressively to the anchor used as a pulley before knotting. The patients were immobilized for three weeks, limiting flexion to 0–90°, then 45–130° the three following weeks.

Results: For the nine patients, there were no cases of sepsis nor radioulnar synostosis. Three cases of calcification were noted and to cases of nervous complications which resolved totally. Six patients, mean age 44.8 years (range 34–54 years) (two patients had moved away from the region) were reviewed at mean 19.2 months (range 10–33 months). Force at maximum flexion was 94.6% of the opposite side (range 58–131.5%). Repeated supination was somewhat bothersome for two patients. None of the patients complained of work impairment and all resumed their activity at the same level within 4.6 months on average. The MRI analysis (available in five patients) demonstrated that the reinserted tendon was in contact with the bone and that ther was a visible bone-tendon junction: the anterior and posterior borders of the tendon, as well as the fivers, showed a regular configuration. The terminal part of the tendon was enlarged in 3/5 cases. The tendon signal from the last 3 cm was variable: low intensity signal on T1 and T2 sequences or discrete high intensity signal on T1 and T2. There was no evidence of peritendinous effusion. At the time of the MRI evaluation, the anchors had not been resorbed.

Discussion: Several studies have reported the usefulness of reinserting the branchial biceps in manual laborers. The half-approach techniques, especially by anchorage, avoid the double-approach, enabling less traumatic reinsertion. The branches of the radial nerve must be carefully identified (we observed only resolutive cases of nervous deficit). Nevertheless, this type of reinsertion has not been evaluated. There is no proof that the reinserted biceps remains in an anatomic position. Our MRI findings are in favor of continuing the single-strand suture technique since the evidence demonstrated the validity of this type of transosseous suture.

Purpose of the study: Functional recovery afte displaced cephalotuberosity fracture of the proximal humerus in pateints aged over 70 years is a major surgical challenge. Reconstuction with an inversed prosthesis avoids the problems of tuberosity fixation. We report a prospective consecutive series of reversed prostheses used of 3 and 4 fragment displaced and non-displace fractures in patients aged over 70 years.

Material and methods: Between January 2001 and June 2004, 19 patients aged over 70 years were included in this study, 16 women and 3 men, mean age 74.9 years (range 58–94 years, median 76 years). All presented 3- or 4-fragment fractures. An independent operator established the Constant and Dash scores. The position of the implants, loosening, presence of a glenoid notch (Nerot) were noted on plain x-rays.

Results: Sixteen of the 19 patients (13 women, 3 men), mean age 73.9 years (range 58–94 years) were reviewed at mean 12.6 months follow-up (range 6–18 months). There were no cases of dislocation. Hematogenous sepsis occurred at 16 months in one patient and led to implant removal. The raw Constant score was 53 (34–76) and the weighted Constant score 76.1 (41–110.1). The Dash score was 37.4 (34–76). Active abduction reached 91.2° (10–150°), active elevation 97.5° (20–150°), active RE1 6.6° (0–50°), active RE2 9.4° (0–90°) and active internal rotation 31.2° (0–60°). There was a humeral lucent line in five cases and a grade 0 glenoid line in one, grade 1 and 2 in six, and grade 3 in three.

Discussion: The only series of fracture of the proximal humerus in patients aged over 70 years was a retrospective study of prosthesis patients reported by Wretenberg in 1997. To date, there has not been a published series on use of the reversed prosthesis for fracture. For the short term in a population with frail bone and minimal functional requirements, reversed implants provide the best subjective and objective functional results. The absence of postoperative immobilization and independence from the rotator cuff enables rapid recovery of useful motion. Range of motion is reduced only to a small extent for rotation. Thus when possible, we reinsert the tuberosities with the reversed implant. Even if the tuberosity assembly dismounts (agitation in a context of temporospatail disorientation), there is no consequence on the reversed prosthesis. The large number of lucent lines with no clinical impact is a point to be examined carefully, showing that further improvement can be achieved with the existing implants.

Purpose of the study: Appropriate treatment for fractures of the distal radius with dorsal displacement remains a subject of debate. Intrafocal pinning is the most widely used technique in France. Plate fixation has been developed to avoid secondary displacement and stiffness sometimes observed after pinning. We compared three osteosynthesis techniques for the same type of fracture (extra-articular with dorsal displacement).

Material and methods: Sixty-two consecutive patients underwent osteosynthesis using the following techniques successively: posterior plates [20 patients mean age 59.9 years (range 25–87 years)], intra and extra-focal pînning [22 patients mean age 55.6 years (range17–83 years)], the anterior plate [20 patients mean age 57.1 years (range 17–78 years)]. An independent operator evaluated all patients using the Herzberg, Gartland and Werley and Dash scores. The radial slope in the frontal plane, sagittal tilt, and ulnar variance were measured and compared between the preoperative and last follow-up values. Kruskall-Wallis or ANOVA were applied as appropriate for continuous variables and the chi-square test for non-continuous variables. P< 0.05 was considered significant.

Results: Mean operative time was equivalent for the two plate fixation techniques and twice as long as for pinning. There were more complications in the posterior plating group (32%) and less satisfactory function score despite a two-fold longer follow-up and a smaller number of operators. The best results were obtained with the anterior plating group in terms of range of motion (flexion-extension), Dash, preservation of ulnar variance and presence of a largest number of excellent and very good outcomes according to Gartland. The pinning group provided the best results in terms of sagittal slope. The pinning and anterior plating groups had equivalent range of motion for supination pronation and the same rate of complications (5%). Irrespective of the treatment arm, the Herzberg scores and the Gartland and Dash scores were better: in men, in patients aged less than 30 years, in patients with an associated fracture of the apex of the ulnar syloid process rather than its base.

Discussion: While posterior plate fixation is logical (approach on the side of the injury), the technique is difficult and can lead to nerve and tendon complications. For these extra-articular fractures, pinning like anterior plating can provide good functional results. Pinning is a rapid procedure and anterior plates do not have to be removed, allowing more rapid recovery of total independence.

Aim: Treatment of unrecons tructible comminuted fractures of the radial head remains a therapeutic challenge. There is limited information on the outcome of management of these injuries with metal radial head implant. Before choosing one of them, two groups of patients were rewieved in a retrospective study comparing resection and Swanson implant.

Material and methods: 39 patients sustained unreconstructible radial head fracture between 1969 and 1992. Two groups of 24 patients were reviewed clinically and radiologically by a surgeon not involved in treatment. Functionnal outcomes of the elbow (morrey scoring – SOO scoring system, instability, cubitus valgus) and involvement of the wrist (pain, grasp, RUD instability) were evaluated with a mean follow up of 15 years (6–27,7). Elbow or wrist arthritis, ulnar variance, and evolution of Swanson implant’s were evaluated on standard Xray. 1/2 patient was a man and 1/3 cases consisted in a professional injury. Resec tion group: 16 patients with a mean age of 39 (19–65), treated with a mean preoperative delay of 29,6 days (0–150) were rewieved with a mean follow up of 18,9 years (6–27,7). There were 75% Mason type-III injuries associated with dislocation of the elbow in 18% cases. Swanson group: 8 patients with a mean age of 36 (21–57), treated with a mean preoperative delay of 4,1 days (0–15) were rewieved with a mean follow up of 12 years (8,1–20). There were 88% Mason type-III injuries with no dislocation in that group.

Results: The following criteria did not show any significant differences between both groups: Morrey scoring 77/100, SOO scoring 7,4/11, mean flexion was 130°, mean deficient extension was 18°, mean pronation 60°, mean supination 67°, grasp reached 90% of the contralateral side. Arthritis was pointed in same frequency at the elbow level (87%), and wrist level (66%) in each group. 94% of pa tients in resection group and 89% in Swanson group were satisfied. Excellent and good results are reported most frequently in Swanson group (37% resection group, 51% Swanson group). In resection group following complications were significantly more frequent: ulnar nerve irritation (2x), ulnar head dislocation (2x), ulnar head instability (3x), paraarticular ossification (5x), ulnar variance positive in all cases (mean value 3,20 mm). In the Swanson group only one implant was destroyed at the follow up.

Aim: The purpose of the study was to evaluate the feasibility of Norian SRS bone cement injected into a distal radius following reduction and stable fixation in preventing shortening and loss of pronation-supination.

Material and methods: Between 1998 and 2000 48 patients with a mean age of 65 (54–82) sustained distal radius fracture (AO classification stage A in 26 cases, B in 15 cases, C in 7 cases) with metaphyseal comminution. Functionnal and radiological outcomes of the wrist (O’ Brien scorring, Gartland and Werley scoring, DASH) were evaluated with a mean follow up of 46 months (36–56) by a surgeon not involved in treatment. Fixation was performed in 34 cases by pins, in 14 cases by dorsal plate, in 2 cases by external fixator.

Results: 4 patient lost of follow up and 5 mal union were excluded of final evaluation. 3 RSD were pointed on the 39 evaluated patients. O’ Brien scoring reached 84/100 (54–100), Gartland and Werley scoring reached 4,6 (0–11) with 89% excellent and good results, DASH reached 23,6 (5,8–62,7). Ulnar variance changed less than 2mm between postoperative time and maximal follow up in 88%. There were no clinically adverse effects but one case of volar extrusion of injected Norian was pointed with resolutive evolution. Bone substitute was always in place at the longest follow up.

Discussion: Adams, Pogue, Mc Queen pointed the bio-mecanical and clinical advantage to fill the void secondary to the comminution to avoid the shortening of the radius. First cases reported by Kopylov and Jupiter, and prospective series of Kopylov, Sanchez Sotello and Cassidy proved the interest of an adaptative injectable cement in case of comminution. Injectable bone substitute allows to maintain the ulnar variance in competition with bone graft or bio ceramic.

Conclusion: Norian is able to fill a metaphyseal void but fixation of the fracture remains necessary.

Purpose: Appropriate treatment of fractures of the acetabulum is well known but there is a risk of subsequent degeneration. Few reports of series reviewed after ten years are available. We report a series of 136 treated fractures of the acetabulum with a mean follow-up of 16 years.

Material and methods: Between 1972 and 1996, a total of 554 fractures of the acetabulum were treated. An independent operator reviewed 136 cases. The Judet Letournel classification was applied. Reduction was studied on the AP and 3/4 oblique views of the pelvis using the SOFCOT (November 1981) criteria. Intra- and postoperative parameters (blood loss, complications) were noted. Functional outcome was assessed with the Postel-Merle-d’Aubigné score.

Results: Orthopaedic treatment was used for 38% of the fractures. Forty-one percent were non-displaced and 54% were minimally displaced; 5% of patients had a contraindication for surgery. Reduction was achieved in 28% of the displaced fractures. Among the patients treated orthopaedically, 71% had a good or very good outcome. Anatomic reduction was achieved in 80%. The main complications were sciatic nerve injury (14%), heterotopic ossifications (18%), infection (5%) and intraarticular screws (5%). Good or very good outcome was achieved in 69%. A total hip arthroplasty was implanted in 19% at mean 8 years. Factors significantly related with poor outcome (p< 0.05) were age, posterior displacement, and surgeon experience. There was a good correlation between the function score and radiological signs of osteoarthritis.

Discussion: This is the longest follow-up reported in the literature. For operated patients, the percentage of good and very good outcomes was lower than in other series despite a good rate of anatomic reduction which thus is not a guarantee of good long-term outcome. Other prognostic factors found in the literature include fracture of the femoral head, type of fracture, and quality of the reduction. Long term follow-up remains essential for pertinent analysis of joint surgery.

Purpose: We report our experience with costal osteochondral autografts of the scaphoid for the treatment of radioscaphoid osteoarthritis complicating chronic scapholunate non-union or dissociation.

Material and methods: The technique was used for nine patients from 1994 to 2001 (eight men and one woman, mean age 45 years, age range 26–62). The proximal two-thirds of the scaphoid were resected. An osteocartilaginous graft was harvested from the ninth rib and after remodelling to the scaphoid cavity was fixed to the base of the scaphoid with a Kirshner wire.

Results: Mean follow-up was 2.5 years. Pain improved significantly in all patients. Force was 80% on average compared with the healthy side. Mean wrist motion in flexion and extension was 91° (70–150°).

Conclusion: This technique has provided encouraging preliminary results in terms of restored force and wrist motion. It is an interesting alternative to conventional techniques.