Introduction

Locking nail have considerably improved the treatment of long weight bearing bones. However, distal locking needs experience and may expose to radiations. Many methods have been proposed to facilitate distal locking and improve safety. Recently, an external distal targeting device adapted to the ancillary of the Long Gamma Nail has been proposed. We report our experience with this device through a comparative series of distal lockings. Aim of this work was to assess feasibility and advantages brought about with this targeting device when considering time or dose of irradiation.

Purpose of the study: Computed tomography is recommended for the preoperative work-up of joint fractures as it allows an optimisation of the access as a function of the injury. During the operation, 2D radiographic or fluoroscopic controls are still widely used. After one year’s experience, we evaluated the potential pertinence of using 3D reconstructions intraoperatively with a mobile isocentric fluoroscope (iso-C-3D).

Material and methods: All operations for which the amplifier was used were collected prospectively. The type of fixation as well as the details of the installation and measures taken intraoperatively were noted.

Results: At one year, intraoperative 3D reconstructions were made during 48 operations in 47 patients: fracture of the calcaneum (n=13), thoracolumbar spin (n=12), acetabulum (n=11), tibial condyles (n=9), odontoid (n=2), pelvis (n=1). The installation was habitual for the calcaneum and odontoid fractures. For the other localizations, use of a carbon plateau table facilitated good quality imaging for spinal and tibial condyle fractures; a carbon orthopaedic table was useful for acetabulum and pelvis fractures. With the intraoperative 3D reconstruction the surgeon was able to check the freedom of the canal after reduction and fixation. For the calcaneum fractures, reduction of the thalamic fragment was revised in one patient; in another, an intra-articular screw was replaced. One intra-articular screw stabilizing the posterior wall was also changed during an acetabulum fixation.

Discussion: During our first year of use, 3D reconstruction intraoperatively has allowed us to avoid three early reoperations (for two calcaneums and one acetabulum). Classical 2D imaging of these two localizations is difficult to interpret because of the spherical form of the hip joint and, for the calcaneum, the difficulty in obtaining quality retrotibial images. Quality images requires specific installation, limiting interference with metallic supports.

Conclusion: The results we have obtained in our first year of use of the ISO-C-3D amplifier has led us to generalise its use for percutaneous fixation procedures involving the acetabulum and the calcaneum.

Purpose of the study: We report a prospective consecutive series of femoral fractures on prosthesis. The goal was to evaluate mid-term outcome of treatment with a locking plate.

Material and methods: From June 2002 to December 2007, we treated 35 patients (1 bilateral), 28 female and 7 male, with a fracture around their total hip arthroplasty (n=21), total knee arthroplasty n=7), unicompartmental knee prosthesis (n=1), between a THA and a TKA (n=2), or between a trochanteric osteosynthesis and a TKA (n=5). Mean age was 76 years (39–93). For the majority, osteosynthesis was achieved via a mini-invasive incision, using a locking plat (Synthes^®) bridging the implant in situ. The rehabilitation protocol consisted in immediate weight-bearing for most of the cases.

Results: At revision, one patient was lost to follow-up, one was an early failure, and seven patients had died, including four which were retained for the analysis because data was available for 24, 40, 43 and 67 months respectively. The analysis thus included 30 patients with 31 fractures and mean 26 months follow-up (range 6 – 67 months). The following results were obtained for the initial series: mini-invasive surgery (n=26), access to fracture focus (n=10), total postoperative weight bearing (n=20), partial weight bearing at 20 kg (n=3), no weight-bearing for six weeks (n=13). Complications were: infection (n=2), general (n=2), disassembly (n=3, one femoral stem replacement and two revision ostheosynthesis). Bone healing was obtained in all cases except one. There was a misalignment > 5 in five cases. At review, there was no implant loosening.

Discussion: This work shows that locking compression plates inserted via a mini-invasive approach followed by weight-bearing is a feasible option. This technique combines the principles of closed osteosynthesis with preservation of the haematoma and stability of osteosynthesis material. The rehabilitation protocol was developed in consideration of the nature of the material. The locked plate acts like an internal fixator, allowing increased implant stability. Screw hold appeared to be sufficient to allow early weight-bearing.

Conclusion: Use of locking compression plates for femoral fractures on osteosynthesis implants is effective. The stability of the assembly allow, despite the age of the patients, early weight-bearing and walking, with a stable outcome over time.

Purpose of the study: Revision total knee arthroplasty (rTKA) is becoming a routine procedure. The technical problems are greater than with a first-intention implantation because of the potential malposition of the initial implants, loss of bone stock, and prior ligament injury. It could be hypothesised that as for implantation of a primary TKA, navigation might improve the quality of the implantation.

Material and methods: We used the Orthopilot™ (Aesculap, RFA) navigation system for first-intention TKA. The standard software was used for revisions. The acquisition of the anatomic and kinematic data was performed while the initial implants in situ. The implants were then removed. Any bone recuts required were done under navigation control. The size of the implants and their thickness were determined after digital simulation of residual laxity; ligament balance was adapted from this data. The system does not allow navigation for centromedullary stem extensions nor for filling potential bone defects. Sixty patients underwent the procedure. There was a comparative series of 30 patients who underwent manual conventional revision using an instrumentation guided by the centromedullary femoral and tibial stems. The quality of the implantation was determined by measuring the alignment of the limb and the orientation of the implants on the postoperative x-rays. Outcome was analysed with Student’s t test and the chi-square test with p< 0.05 taken as significant.

Results: There was a significant improvement in quality of the implantation for all radiographic criteria in the navigation group. Limb alignment was restored in 88% of the navigated cases and 73% of the conventional cases. Similar differences were observed for femoral and tibial implant position on the lateral and AP views.

Discussion: The objectives set for implant orientation and ligament balance can be met with the navigation system for the majority of knees, with a rate similar to that achieved with primary implantation. The navigation system is an appreciable aid for these often difficult procedures where visual information can be misleading.

Conclusion: The navigation system used here facilitated revision TKA.

Introduction: Preoperative use of tomodensitometry is a common practice when assessing fractures with intraarticular involvement, helping to determine the most appropriate surgical approach according to the lesions observed. To date, during the surgical procedure itself, radiographical or fluoroscopic controls still largely rely on two dimensions X rays. We assessed the possible benefits of intraoperative tridimensional reconstructions using mobile isocentric fluoroscopy (iso-C-3D) after one year of use.

Material and Methods: All the procedures where intra-operative tridimensional fluoroscopy was used were assessed prospectively for one year. The type of osteosynthesis as well as specific modalities of installation and therapeutic measures driven from analysis of the images were analyzed.

Results: During the first year of use, intraoperative tridimensional reconstruction had been carried out in 48 procedures in 47 patients. The region involved was calcaneus 13 times, thoracolumbar spine 12 times, acetabulum 11 times, tibial condyles 9 times, axis 2 times and pelvis one time. Installation was the same than usually performed in the cases of calcaneus and axis osteosynthesis. For the other localisations, obtention of good quality images was facilitated through the use of a carbon table for spine and osteosynthesis of the tibial condyles, and through the use of a carbon traction table for acetabular or pelvic fractures. Intraoperative tridimensional reconstruction allowed to check for freedom of the vertebral canal after reduction and osteosynthesis of the spine. in the cases of fracture of the calcaneus, reduction of one thalamic fragment was improved in one case and one intraarticular screw could be changed in another case. In the case of acetabular surgery, one screw stabilizing the posterior wall was found intraarticular on tridimensional reconstruction and could be changed before closure.

Discussion: Intraoperative tridimensional reconstruction, during its first year of use, allowed to avoid 3 early reinterventions (for 2 calcaneus and one acetabulum). Accurate interpretation of standard plain X ray in these two localizations is difficult because of the spherical shape of the hip joint and because good quality imaging, especially the retrotibial view, is hardly obtained intraoperatively in fractures of the cacaneus. When using tridemensional reconstructions, acquisition of good quality images has to be anticipated during the installation of the patient, limiting any interfereces with metallic supports to a minimum.

Conclusion: the results obtained over the first year of use of intraoperative tridimensional reconstructions with the ISO-C-3D encouraged the authors to generalize its use when performing osteosynthesis of the acetabulum or calcaneus as well as percutaneus osteosynthesis of articular fractures.

Purpose of the study: Since 2001, we have used arthroscopy systematically to control the treatment of distal radius fractures. We report our three years experience.

Material and methods: Arthroscopic control was used for all patients aged less than 65 admitted to our unit for treatment of an articular fracture of the distal radius. The same operator performed all procedures. Fixation methods were: K-wire pinning, locked plating (Synthes) or a combination of these two methods. The arthro-scope had a 2.4 mm optic. Bony lesions were noted according to the Cataign, Fernandez and AO classifications. The DASH, Green and O’Brien, and PWRE scores were noted.

Results: Intraoperative arthroscopic control was performed for 61 patients between November 2001 and November 2004. Mean follow-up was 17 months (range 6–36 months). Arthroscopic exploration revealed: scapholunate ligament tears (n=11), lunotriquetral ligament injuries (n=3), pathological perforations of the triangle complex (n=4), damage to the radial cartilage (n=15), and mirror involvement of the carpal cartilage (n=4). An arthroscopic procedure was necessary to treat a bone or ligament lesion in 28 cases. At last follow-up, the DASH score was 19.3 and the PWRE 37.6.

Discussion: Arthroscopic evaluation of articular fractures of the distal radius, a routine practice in English-speaking countries, remains a limited practice in France. There is nevertheless a real advantage of using intraoperative arthroscopy. The particular anatomy of the radial surface makes it impossible to achieve proper assessment on the plain x-ray for a quality reduction of the fracture. Recent ligament injuries are rarely detectable on a wrist x-ray. An intra-articular stair-step or an untreated ligament injury can pave the way to short-term development of osteoarthritic degeneration. Intraoperative arthroscopic control is the only way to diagnosi and treat these osteoligamentary lesions observed in patients with an articular fracture of the distal radius. For us, non use of intraoperative arthroscopy constitutes a lost chance for patients with an articular fracture of the distal radius.

Purpose: We report preliminary results after treatment of humeral fracturs with a Targon centromedullary nail (Aesculap(r)).

Material and methods: Forty-five patients, predominantly women, underwent surgery from June 2001 to June 2002. Mean age was 63.5 years. The right side predominated. The series included 28 proximal fractures (65.9 years): 3-4 fragments (n=14), two fragments (n=8), pathological fracture (n=3),metaphyseo-diaphyseal fracture (n=3); and 17 shaft fractures (59.5 years): pathological fractures (n=4), nonunion (n=3), trauma (n=10). The Beach position, fractured limb free, was used with a superolateral approach. We inserted 28 Targon PH nails, including nine long nails, for proximal fractures and 17 Targon H nails for shaft fractures. Nail diameter was 8 mm. Nails were locked with four self-locking proximal screws (5 mm) and two distal screws (3.5 mm). The patients were immobilised with an arm to body brace. Hanging limb exercises were initiated immediately and active exercises at bone healing. The Constant score and radiographic measures were recorded at last follow-up.

Results: Mean follow-up was 12.2 months. We had six deaths and five patients lost to follow-up. Bone healing was achieved at eight weeks on average. Fracture reduction was acceptable for 37 limbs, including three which required open reduction. There were nine postoperative complications: superficial infection (n=1), distal screw pull out (n= 3), distal screw fracture (n=1), nail fracture (n=1). The mean Constant score was 69 (30–96).

Discussion: Proximal fractures of the humerus are often comminuted displaced fractures requiring cephalic arthroplasty. Total functional recovery is often difficult leading to mid and long-term problems for this young population. Stable quadruple proximal locking, associated with good filling of the canal by the nail enables fracture stablisation and satisfactory maintenance of the tuberosities. This stable assembly allows early rehabilitation. These advantages are particularly important for shaft fractures in young patients. The material does however have certain limitations related to fragility of the distal screws which are situated near the circumflex bundle for the Targon PH nail.

Conclusion: Our early results are encouraging for humeral fractures, both in elderly and young patients. This type of osteosynthesis can be a useful alternative to arthroplasty and allows early rehabilitation necessary for good functional recovery.

Purpose: We compared three fixation systems for proximal fractures of the humerus to elaborate a rigid extra-medullary implant: the basket plate. This novel implant allows fixation of the tubercles with a claw system associated or not with a central cephalic locking screw. The objectives of this study were: check the resistance of the prototype, evaluate the contributions of the claws, and the usefulness of locking.

Material and methods: This was a prototype experimental study comparing a commonly used implant (Maconor2 plate) with the new implant using two series of static mechanical tests (Instrum). The tests were performed on 20 DMO-frozen anatomic specimens using the four-fragment fracture model. An implant was assigned to five groups of randomly selected specimens. The first tests (three groups) were axial compression tests mimicking abduction in the plane of the scaphoid. We analysed the overall mechanical behaviour of the implant and evaluated the locking system. The second tests (two groups) were traction tests. We analysed the behaviour of the fixed tuberosities. The mechanical resistance of the assemblies was noted as the limit load on the force: deformation curve and as the rigidity of the slope.

Results: The first tests showed that the implant was improved by the locking system and had better overall mechanical characteristics than the compared implant, although the difference was not statistically significant. The better hold in the tubercles provided by the claws was expected after the first tests and confirmed by the second tests, but the difference was not significant.

Discussion: The prototype improved with the locking system presented mechanical resistance equivalent to the compared model. The usefulness of locking could not be demonstrated but was considered to improve tolerance to loading by better force distribution. The contribution of the claws was not demonstrated statistically although the results are in line with early hopes. The present findings and data in the literature on shoulder biomechanics suggest that the tests should be conducted on a larger number of specimens to demonstrate a statistically significant difference. The tested series was too small.

Conclusion: Comparison of mechanical resistance with theoretical data on forces applied to the proximal humerus show that the prototype is well adapted, allowing immediate postoperative motion. A prospective study is currently being conducted in our unit.