Purpose of the study: Acute compartment syndrome of the leg can lead to serious sequelae affecting patient autonomy. Retractile postischemic fibrosis leads to various deformities of the ankle and foot from simple claw toe to complex multidirectional dislocations. Aggressive surgery, or even amputation, may be needed to save soft tissue. Data are scarce on management practices for these deformities. We present a long-term follow-up.

Material and method: From 1981 to 2006, 150 patients with a compartment syndrome of the leg were managed in our unit. Ten of these patients later required repeated surgery directly related to the sequelae of the compartment syndrome affecting the foot and ankle. These patients were followed in our unit. Personal data, as well as potential risk factors and sequelae were noted. Data were analysed and compared with reports in the literature.

Results: For nine of the ten patients, the initial diagnosis was established late, for seven, more than 24 hours after onset. The anterior and lateral compartments were involved (10/10 and 9/10) and less often the deep posterior compartment (3/10), motor deficit (3/10) and sensorial deficit (5/10) of the tibial nerve. The deep posterior loge was the cause of late equine deformity in eight patients. Functional outcome was good in eight patients after secondary surgery. For the other two cases, leg amputation was the only solution.

Discussion: Complicated acute compartment syndrome of the leg most commonly involves the anterior and anterolateral compartments. Conversely, the posterior compartment is implicated in the development of invalidating sequelae. We analysed the different procedures used in the literature for managing these sequelae and established a classification. Effective treatment of the foot and ankle affected by a late postischemic syndrome depends on a rigorous surgical strategy taking into account the multidirectional and multifactorial aspects of the resulting deformity. Prevention nevertheless remains the most effective treatment, both by early initial aponeurotomy and by prevention of the secondary deformity.

Purpose of the study: The relative role for anterograde nailing in relation to retrograde nailing has become a highly debated issue. Bifemoral fractures would appear to be a priority indication for the later method.

Material and methods: From January 1997 to December 2003, 19 bifemoral shaft fractures were treated by simultaneous retrograde nailing (group 1, eight cases, five males, three females) or by anterograde nailing in a one-stage procedure (group 2, eleven cases, six males, five females). Patient age was 23 years 7 months on average (range 16.6–40.5 years) in group 1 and 26 years 7 months (range 17.8–42.3 years) in group 2. The ISS was 30.6 (13–50) in group 1 and 16.8 (10–27) in group 2.

Results: The time for installation of the two femurs was 30 min (range 20–40 min) in group 1 and 70 min (range 60–80 min) in group 2. The operative time for the two femurs was 144 min (range 110–170) in group 1 and 156 min (range 140–180 min) in group 2. One patient in group 1 died on day 2 postop; none in group 2. First-intention bone healing was achieved at 14 weeks (range 12–16) in all patients in group 1. In group 2, there were two nail replacements and two grafts. Healing time was 24 weeks (range 10–130). Follow-up was 24 months (range 13–54 months). Knee flexion was 138° (range 130–140°) in group 1 (removal of patellar tendon calcification in one patient) and 123° (range 110–150°) in group 2. The difference in length between the two femurs was 6.2 mm (range 0–6 mm) in group 1 and 5.3 mm (range 0–11 mm) in group 2. The functional outcome (Thorensen criteria) was excellent in nine femurs, good in five in group one and excellent in nine, good in nine and fair in four in group 2.

Conclusion: Retrograde nailing provides clinical and radiographic results which are comparable to antero-grade nailing. However, the time required and the ease of installation is in favor of retrograde nailing.

Purpose: Shaft fractures are not uncommon in elderly subjects who have proximal osteosynthesis material. There are several options for the surgical technique and the fixation method, the choice depending on their aggressiveness.

Material and methods: Between January 1998 and January 2002, retrograde nailing with proximal locking using the fixation screws already in the femur was used for eight women aged 79–99 years (mean 92). The classical ascending nailing procedure was used to insert a Russell-Taylor nail in six patients and a supracondylar Stryker nail in two. The proximal locking was used by apposing the fixation screw, which implied coinciding the locking holes in the nail with the plate screws. This required using only one screw for locking in some cases because of the distances between the holes.

Results: There were no infectious complications. Fracture alignment was correct in all cases. Subjectively, total recovery of motion and independence was achieved. Likewise for pain relief although assessment was difficult. Bone healing was achieved in four months. Secondary varus displacement occurred due to insufficient hold of the proximal locking screw in the medial cortical.

Conclusion: Although not perfect, the retrograde nail locked in the proximal implant provides a satisfactory solution for these often debilitated elderly patients. This option enables a minimally aggressive operation allowing a composite osteosynthesis protecting the entire femur without imposing points of peak stress.