Purpose of the study: Because of the difficulty of maintaining anatomic reconstruction, plate fixation is limited for complex fractures of the calcaneum. Implants with angular stability can broaden classical indications and improve outcome.

Material and method: From February 2004 to February 2008 we treated 35 articular fractures of the calcaneum: 26 male, 6 female, 3 bilateral cases, mean age 41.46±15.99 years, age range 17–71, ≥ 3 displace fragments [Duparc IV:16; Duparc V: 16], preoperative CT [Sanders III: 22; IV: 13]. The surgical procedure was performed by one operator on days 4 to 7: lateral wide-L incision; articular and extra-articular reduction; lateral fixation using an AO-LCP^® plate with locking screws. Intra- and postoperative X-rays (Boehler angle, talo- and cubocalcaneal congruence), postoperative CT. Rehabilitation: mobilisation of the talocalcaneal joint on day 21; partial weight bearing after 2 months; complete weight bearing after 3 months. Radiological and clinical (Kitaoka) follow-up every 60 months.

Results: Anatomic joint reduction was achieved and maintained by osteosynthesis (35/35). Late healing (smoking) (6/35). Healing: 2 months (21/35), 3 (14/35). Plate failure at 3 months without displacement (2/35). Anatomic joint reduction sustained ≥12 months (35/35). Gait without crutches after three months (35/35). Infection at 12 months (1/35). Mean follow-up (40 months, range 12–60).

Discussion: The purpose of surgical treatment is to achieve anatomic reconstruction of all joint surfaces and restore calcaneal height, length, width and alignment until bone healing. Complex joint fractures with a high risk of loss of correction or secondary nonunion have limited the use of conventional reduction-osteo-synthesis methods in favour of first-line reconstruction-arthrodesis. These complex fractures require plates with multiple fixations to maintain stability. Optimal recover of function can be achieved if the anatomic reduction of the joint surface and extra-articular elements can be maintained stable from the start and sustained to healing, demonstrating the usefulness of reconstruction. No series has reported this innovating therapeutic concept.

Conclusion: The reconstruction plate with locked screws enabled osteosynthesis of the most complex calcaneal joint fractures for which the discussion remains open concerning the role of osteosynthesis. The resistant fixation of all the fragments using screws with angular stability enabled stable reconstruction without loss of primary reduction, either secondarily or late, and allowed rapid rehabilitation. The long-term stability of the anatomic reconstruction guarantees good functional outcome which persists over time.

Aims: Internal Fixation of complex calcaneal articular fractures is debated: a perfect and upheld reduction is challenging. Could locked screws calcaneal plates drive back the limits of Internal Fixation instead of initial arthrodesis, involve a faster rehabilitation and improve the results?

Methods: Between 2004 and 2008, 32 patients (26 men, 6 women), sustained 35 complex calcaneal articular fractures. Age: 41.46 [17–71] ±15.99 years. Pre operative TDM: ≥3 displaced articular fragments (Sanders III: 22 and IV: 13). ORIF by the same surgeon, between D4 and D7, through a lateral approach and using an AO LCP^® locked screws calcaneal plate. Intra operative X-ray controls, postoperative TDM. Articular re-education at D30. Complete weight bearing at D90. Follow-up until 60 months (X-ray and Kitaoka score).

Results: Obtained and upheld anatomical articular reduction -Boehler’s angle, talo and cubo-calcaneal congruence-: (35/35). Bone healing: 8 weeks (21/35) and 12 weeks (14/35). Delayed wound healing -smokers-: (6/35). Anatomical articular upholding after 12 months: (35/35). Plate ruptures at D90 without displacement: (2/35). Walking without crutch after D90: (35/35). Mean follow up: 40 months.

Conclusion: Locked screws calcaneal plate used for the fixation of complex articular calcaneal fractures showed no displacement in the primary and secondary healing time. These facts limit the place of initial arthrodesis and streamline the initial recovery process. This may be beneficial for clinical use and the long term follow-up.

Purpose of the study: The appropriate treatment for massive irreparable rotator cuff tears is a subject of debate. The purpose of this work was to analyze at mean five years follow-up a series of 16 shoulders treated with a latissimus dorsi flap.

Material and methods: These 16 patients (seven women) were aged 56 years on average. The procedure was a revision for four shoulders. The tears were all posterosuperior tears and caused invalidating pain in all patients. Mean anterior elevation was 93°. External rotation was 12°. The Constant score, assessed in eleven patients, was 27 points on average. The subacromial space measured 8 mm on average. Supraspinatus fatty degeneration was grade 2 in 45% and grade 3 in 55%. Infraspinatus degeneration was grade 3 in 80% and grade 4 in 20%. The latissimus dorsi flap was associated with a teres major flap in four shoulders and with a deltoid flap in seven. The semi-sitting position was used for 15 of the 16 patients.

Discussion: Treatment of massive irreparable rotator cuff tears is a controversial issue. When the subacromial space is preserved, the presence of muscle atrophy and tendon retraction despite forced mobilization it is logical to use several muscle transfers. This small series demonstrated that a significant improvement can be obtained. Nevertheless the postoperative period is long and indications must remain limited. We discuss our results in comparison with other reported series.

Purpose of the study: The purpose of this work was to report our experience with three patients who underwent hand transplantation procedures following traumatic amputations.

Material and methods: The three patients underwent surgery in 1998, 2000, and 2003. One hand was transplanted in one patient and two in two patients. The technical principles of autologous macro-re-implantations were applied. The re-implantation level was the forearm in all cases. Medical treatment prescribed for life was similar to treatments currently used for renal transplantation (tacrolimus, mofetil mycophenolate and prednisolone).

Results: After an apparent initial success, the first transplanted patient (one hand) had to be re-amputated 2.5 years later due to poor tolerance and poor treatment observance. For the two patients transplanted (two hands for both) in 2000 and 2003, the functional outcome in terms of recovered sensitivity (tact), motricity, and function were quite satisfactory in light of the handicap of bilateral amputation. Immunosuppressor treatment was well tolerated at 1.5 and 4.5 years respectively.

Discussion: Due to the lack of prior experience reported in the literature, we examined the risk-benefit ratio of these re-implantations which must still be considered as clinical experimentation. It is important to consider the potential benefit of myoelectric prostheses as well as the known complications related to immunosuppressor treatments. Patient motivation is also an important factor to consider.

Conclusion: These three cases demonstrate that the outcome of orthopedic composite tissue allografts in patients given immunosuppressor therapy is quite variable at less than four years follow-up. Experience with a larger number of patients will be necessary before broadening potential indications.

Aims: Functional outcome following pelvic ring fractures is closely correlated with the anatomic results. ORIF is correlated with good anatomic results but with morbidity. Isolated sacro-iliac screws are inadequate. We assessed outcome after complete Minimal-Invasive-Surgery. Methods: Between 1998 and 2001, 21 consecutive patients with unstable pelvic-ring disruptions [15 AO C, 6 AO B] were treated operatively. In a supine position, after close reduction of the fractures, anterior þxation, percutaneous stabilization of the posterior lesions was accomplished using ßuoroscopically-guided ilio-transsacral 7,3 mm cannulated lag-screws inserted through the body of S1 to the opposite sacroiliac joint. Results: Delay from injury to þxation was 4 (0–8) days. 13 anterior þxations and 21 ilio-transsacral cannulated screws were placed. No secondary complications. The main outcome was 2 years; radiographically, 19 anatomic reductions of the posterior fractures and 2 vertical ascensions (5 mm) were achieved. The mean Majeed score was 95. Conclusions: Early stabilization of instable pelvic-fractures in a supine position using percutaneous ilio-transsacral screws and anterior þxation is a technique that lends itself to a variety of unstable pelvic fractures. This diminishes potential blood loss and operative times in multiply injured patients. An obvious limitation in the percutaneous technique is the inability to restore the normal anatomy. Surgical stabilization allows early mobilization of the patients, prevents progressive deformity and obtains good functional results.

Purpose: Good functional results for unstable fractures of the pelvis require reduction and fixation of the posterior lesions. “Open” techniques are highly invasive and sacroiliac screwing is insufficient alone. We evaluated results with a strategy based on minimally invasive complete reduction and osteosynthesis allowing early mobilisation.

Material and methods: The series included 19 men and two women, mean age 30 years (17–60) operated on between 1998 and 2000. Nineteen patients had multiple injuries. The AO classification was A5 C (12 CI unilateral, 3 (2 C2, 1C3) bilateral) and 6B (4 B1, 3 B2). The patients were operated on in the supine position with traction on the lower limb to reduce the hemipelvis ascension. Displaced anterior fractures were reduced and stabilised with a pubic plate or with an anterior external fixator. The posterior fractures were fixed with a percutaneosus canulated cancellous screw measuring 7.3 mm in diameter inserted transacrally into the S1 body to reach the opposite sacroiliac joint under fluoroscopic monitoring. The radiographic results were analysed by measuring the vertical ascension of the hemipelvis at the foot of the sacroiliac and clinical results with the Majeed score.

Results: The patients were operated on day four 0–8) after trauma. Anatomic reduction was achieved in 19 cases, with a gap of 5 mm in two cases. Thirteen anterior fixations (eleven plates, two external fixators) and 21 transacral screw fixations were used to stabilise the pelvi. There were no notable complications. One patient died early from multiple injuries. All were followed for one year after the accident and no secondary dismanteling has been observed. The final mean Majeed score was 95/100.

Discussion: Reduction is best if achieved early. With the transacral screw fixation, it is achieved in the supine position which is technically difficult due to the known anatomic variability of the sacrum. It also allows simultaneous treatment of C13 and C23 comminutive fractures. Anterior fixation is complete.

Conclusions: Percutaneous transacral screw fixation and anterior osteosynthesis is a minimaly invasive technique providing reproducible and reliable results for maintaining reduction in a large number of unstable fractures of the pelvic ring. These fixations allow the upright position and mobilisation early. The good anatomic result is maintained leading to a better functional result which should be validated in a longer series.