Purpose of the study: The Al/PE sandwich is a relatively new massive alumina insert for alumina-on-alumina prostheses using a meta-back press-fit cup. Theoretically, the advantages are a less rigid system and easier positioning and removal. The reliability is however still debated. The purpose of this study was to evaluate the 7-year outcomes of a homogenous series of 53 Al/Al sandwich total hip arthroplasties (THA) implanted without cement.

Material and methods: The series included 48 consecutive patients (53 hips) implanted by the same surgeon from 1998 to 2004 using the posterolateral approach. There were 26 men and 22 women, mean age 58 years (42–69). The prosthesis used a metal back cup totally coated with HA, an Al/PE sandwich insert, a modular anatomic femoral head with partial HA coating, and an alumina head (28 mm). All patients were reviewed and assessed clinically using the Harris score (/100) and the PMA score (/18) and radiographically using the Engh and Gruen and Amstutz scores.

Results: None of the patients were lost to follow-up and none died. One patient underwent revision surgery at 84 months for fracture of the alumina insert: the sandwich insert and the head were changed, and the outcome was very good at three years. At mean 84 months follow-up (47–109), the PMA and Harris scores were, on average, 17.7 and 98 (versus 12.3 and 54 preoperatively, p< 0.05). None of the patients complained of squeaking. There was no acetabular migration or lucency and no osteolysis. A partial and isolated lucent line was observe in the Gruen and Amstutz zone 1 and 8 of the femur in 26% of the hips. Calcar atrophy was noted in 17%. Wear was note radiographically measurable.

Discussion: The clinical and radiographic results appear to be very encouraging at mid term, illustrating the excellent resistance to wear of the alumina-on-alumina bearing, particularly in young and active subjects. With the type of implant used, the improvements provided by the anchorage of the alumina insert in the PE and the increased thickness (minimal 4.5 mm), the high rate of insert fracture reported by certain series in the literature was not observed here.

Conclusion: The absence of wear and osteolysis, improved implant design, and potential advantages in terms of positioning should make this system an attractive alternative for alumina-on-alumina implants.

Purpose of the study: Infection is a rare complication of shoulder athroplasty (3% of reverted prostheses), potentially responsive to diverse therapeutic strategies. This work evaluated the clinical and infectious outcomes obtained after management of infectious complications of reverted total shoulder arthroplasty.

Material and methods: This series included 11 reverted shoulder arthroplasties reviewed at mean 39 months. The bacteriological analysis identified predominantly Pro-pionibacterium acnes (54%). Three patients presented an acute infection, five a subacute infection, and three a chronic infection. In this series, six patients underwent a wash-out debridement procedure, two a two-phase reimplantation, and three a one-phase reimplantation.

Results: At last follow-up, three patients died, eight were reviewed. In the wash-out debridement group, one patient developed recurrent infection and two had repeated dislocations; the mean Constant score was 62 points and the ASES score 16/30. In the two-phase reimplantation group, there was no recurrent infection, the spacer broke in one patient, and the mean Constant score was 45 and the ASES score 10/30. In the one-phase reimplantation group, there were no cases of recurrent infection; the mean Constant score was 51 and the ASES score 11.

Discussion: The therapeutic strategy remains a controversial issue for the infected shoulder arthroplasty. Experience with infected knee and hip prostheses is essential. For infected shoulder prostheses, resection was for a long time the advocated solution, allowing cure and pain relief at the cost of major loss of shoulder mobility. Recent series have reported the effect of wash-out, debridement and reimplantation, allowing restoration of function. In the series reported here, the objective was to restore shoulder function as best as possible while achieving cure of the infection.

Conclusion: Although techniques for surgical revision were inspired by experience with the hip and knee, the problems with shoulder infections are different. The unique goal of curing the infection must be revisited. Shoulder function, and in particular range of motion conditioning the functional outcome, should dictate the surgical strategy for these infections.

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.

Introduction. The treatment of complex fractures of the proximal humerus still raises controversy, particularly in those 3 or 4 part fragments fractures, which are at risk for osteosynthesis (poor fixation in poor bone) or for secondary avascular necrosis. Conventional hemi-arthroplasty has currently remained the most common surgical treatment, but the recovery of active mobility remains incomplete and disappointing.

Inverted shoulder arthroplasty has been initially proposed for the treatment of omarthrosis secondary to deficient rotatory cuffs, however its use in acute traumatology has not been yet investigated.

Material and Medthod. We hereby present the results obtained in 43 consecutive patients (41 women and 2 men) which were retrospectively reviewed with a mean follow-up of 21 months (5–58). The mean age was 78 years-old (64–97). There were 5 three-part fractures, 26 four-part fractures and 12 four-part fracture dislocations. All patients were clinically and radiologically assessed, except two, who deceased with incomplete follow-up data.

Results. The clinical outcome was satisfactory with a mean active forward elevation of 97° and a mean active external rotation in abduction (ER 2) of 30°. The mean Constant score was 44 points (16–69). The mean ponderate score was 66% (25–97%). The mean pain score was 12.5/15, the mean activity score was 10.9/20, the mobility score was 17.6/40 and the strength score was 3.6/25. The mean ponderate score of the controlateral shoulder was 105 %(80–130).

The mean ASES score was 9 points (0–19) out of 24. The mean DASH score was 44 points (0–92) out of 100.

Post-operative complications included 3 reflex sympathetic dystrophies, 5 regressive neurological complications, 1 loosening of the deltoid suture, 1 anterior dislocation and 1 acromion fracture. There was no infection.

Radiographs at last follow-up showed peri-prosthetic calcifications in 36 cases, displacements of the tuberosities in 19 cases and scapular notches in 10 cases (1 type III, 3 type II and 6 type I notches). No migration of the prosthetic components was observed.

Discussion. Satisfactory mobility scores can be obtained in the treatment of complex shoulder fractures in the elderly, despite frequent deficiencies of the rotator cuff, whatever their causes, degenerative or traumatic (secondary displacement).

Conclusion. Inverted shoulder arthroplasty might constitute an interesting alternative in the treatment of displaced 3 or 4 part fragment fractures in the elderly over 70. Long term results are required before extending the indications to younger patients or to other types of fracture.

We used an inverted shoulder arthroplasty in 43 consecutive patients with a mean age of 78 years (65 to 97) who had sustained a three- or four-part fracture of the upper humerus. All except two were reviewed with a mean follow-up of 22 months (6 to 58).

The clinical outcome was satisfactory with a mean active anterior elevation of 97° (35° to 160°) and a mean active external rotation in abduction of 30° (0° to 80°). The mean Constant and the mean modified Constant scores were respectively 44 (16 to 69) and 66% (25% to 97%). Complications included three patients with reflex sympathetic dystrophy, five with neurological complications, most of which resolved, and one with an anterior dislocation. Radiography showed peri-prosthetic calcification in 36 patients (90%), displacement of the tuberosities in 19 (53%) and a scapular notch in ten (25%). Compared with conventional hemiarthroplasty, satisfactory mobility was obtained despite frequent migration of the tuberosities. However, long-term results are required before reverse shoulder arthroplasty can be recommended as a routine procedure in complex fractures of the upper humerus in the elderly.

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.