Aims

The pathogenesis of intraneural ganglion cysts is controversial. Recent reports in the literature described medial plantar intraneural ganglion cysts (mIGC) with articular branches to subtalar joints. The aim of the current study was to provide further support for the principles underlying the articular theory, and to explain the successes and failures of treatment of mICGs.

Aims

The primary aim of this study was to define the standard minimum follow-up required to produce a reliable estimate of the rate of re-operation after radial head arthroplasty (RHA). The secondary objective was to define the leading reasons for re-operation.

Aim

Infections after total elbow arthroplasty are more frequent than after other joint arthroplasties. Therapeutic management varies depending of the patient status, the time of diagnosis of the infection, the status of the implant as well as the remaining bone stock around the implants.

Aims

Radial head arthroplasty (RHA) may be used in the treatment of non-reconstructable radial head fractures. The aim of this study was to evaluate the mid-term clinical and radiographic results of RHA.

Purpose of the study: The articulated external fixator of the elbow joint is often useful for the treatment of trauma victims. It can neutralise dislocation forces and protect osteosynthesis assemblies and ligament repairs while authorising early mobilisation. This work reports our indications and application of this type of fixator, as well as the expected clinical and radiographic outcomes.

Material and methods: From 1995 to 2008, 34 patients had an external fixator of the elbow in our unit, in combination with classical treatment. Two groups of patients were distinguished, those with a traumatic injury requiring emergency care (n=15, group 1: six dislocations, two fracture-dislocations, and seven complex fractures), and those treated outside an emergency context (n=10, group 2: ten chronic dislocations or subluxations, four stiff joints, one infection, four material disassemblies). Eighteen patient were reviewed retrospectively, clinically and radiographically. The DASH score and the Mayo Elbow Performance Score (MEPS) were noted. The Broberg and Morrey classification was used for osteoarthritis.

Results: At mean 4.3 years follow-up, for groups 1 and 2, the DASH scores were 35 and 25 points and the MEPS scores 74 and 74 points respectively. In group 1, the range of motion was 63° for flexion-extension; the elbow was centred and stable in all cases except 2 (one posterior subluxation). Six elbows presented moderate to severe osteoarthritis. In group 2, the range of motion was 80° flexion-extension; the elbow was centred and stable in all cases except one (one posterior subluxation). Moderate to severe osteoarthritis was noted in five elbows. There were four complications: two cases of transient (ulnar and radial) paralysis, one fracture of the humerus on a pin track, and one superficial pin track infection.

Discussion: This study demonstrates that the articulated external fixation can maintain the reduction during the healing process for complex elbow trauma where stability is compromised. The morbidity is low and functional outcomes favourable. Early mobilization of these injured elbows can limit secondary stiffness. The prognosis remains a function of the initial injury and the quality of the associated treatments.

Purpose of the study: Both conventional plates (CP) and volar locking plates (VP) are used for the ttreatment of distal fractures of the radius (Crognet 2006, Jupiter 2009). This was a retrospective analysis to compare the respective results of these two plating methods with a one year follow-up and to study the clinical outcomes and quality and duration of the reduction achieved.

Material and methods: From 2005 to 2008, 48 CP and 33 VP were inserted for the same indications, simultaneously in the same unit. The four operators chose the material as needed. The time to treatment was less than 12 hours for 81% of patients. For CP, the fractures were comminutive in 60%, articular in 40% and associated with ligament injury for more than 10%. For VP, the fractures were comminutive in 80%, articular in 86% and in a context of multiple trauma in 20%. The clinical analysis included range of motion, index of reduction (IR), stability (IS) and efficacy (IF) defined at the SOFCOT symposium.

Results: For the two series, the mean range of motion was flexion-extension 118, pronosupination 166; the recovered force was > 75% of the controlateral side. The QuickDash was excellent in more than 75%, good in 10%, fair in 10%, poor in 5%. More than 75% had an anatomic result. Complications were the same in percentage and in type for the two types of plates with no significant difference. For the VP, 95% of the clinical and radiographic outcomes were good or very good. For the CP, the results were the same. There was only one real loss of reduction with migration of an epiphyseal screw with no observable clinical impact.

Discussion: This study was limited by the non randomization; there was a difference in the type of injury between the two series. Use of non-locked plates for fractures of the distal radius has proven efficacy as amply noted in the literature. This was analysed, and in particular with a few comparative CP/VP studies. Locking the volar plate does not guarantee stability in fragile cancellous bone. The problems encountered when removing the VP were not within the scope of this work. The cost of locking can limit systematic use. These two types of plates should not be considered in opposition but rather as complementary techniques.

Purpose of the study: Propionibacterium acnes (PBA) is an anaerobic Gram-positive commensal bacillus of human skin which can cause bone and joint infections (Lutz 2005, Zeller 200, Levy 2008). The purpose of this work was to evaluate over a given period the frequency of PBA infections and the reality of its role as a pathogenic organism.

Material and methods: A retrospective survey of activity from 2006 to 2008 using bacteriology laboratory data identified 34 patients (22 male and 12 female) with at least one sample collected during an orthopaedic or traumatology surgical procedure that was positive for PBA. The mean number of positive samples was 3.6; 17 from the thoracic limb, 17 from the pelvic limb, involving 16 arthroplasties (4 hips, 6 knees, 5 shoulders, 1 elbow), 13 osteosynthesis procedures, 3 cuff repairs and 1 acromioclavicular procedure. Six of 20 histology samples showed a septic granuloma.

Results: The PBA was the only germ isolated in 18 cases; it was associated with other bacteria in 16 cases. Other blood tests were abnormal (WBC 6800 leukocytes, CRP 25mg/L en average). According to the Lutz classification, three groups of infection could be identified: certain infection with clinical signs and at least two positive samples (n=12), possible with clinical signs but only one positive sample (n=5), and probable without clinical signs and one or more positive samples (n=17). Of the 12 patients in the first group, eight had material (three shoulder prostheses, three hips, one knee and one femoral nail), which had to be removed for six with use of a cemented spacer in four. Mean duration of antibiotics was five weeks. Four patients in this group have not yet achieved cure. In the second group, all samples were taken from a thoracic limb and had another germ in four cases; all patients have achieved cure. In the third group, the samples were systematic (two shoulder arthroplasties, two repeated cuff repairs, five revision prostheses, four nonunions and four material removal); only one sample was positive in ten cases and only five patients were given antibiotics; all achieve cure.

Discussion: This series is in agreement with the literature: frequent localization on a thoracic limb, association with another germ, questionable attribution to PBA. Patients meeting the criteria of the first group should be treated. If a PBA infection is suspected, samples should be repeated, with prolonged culture; this attitude should be validated prospectively.

We retrospectively analysed the clinical results of 30 patients with injuries of the sternoclavicular joint at a minimum of 12 months’ follow-up. A closed reduction was attempted in 14 cases. It was successful in only five of ten dislocations, and failed in all four epiphyseal disruptions. A total of 25 patients underwent surgical reduction, in 18 cases in conjunction with a stabilisation procedure.

At a mean follow-up of 60 months, four patients were lost to follow-up. The functional results in the remainder were satisfactory, and 18 patients were able to resume their usual sports activity at the same level. There was no statistically significant difference between epiphyseal disruption and sternoclavicular dislocation (p > 0.05), but the functional scores (Simple Shoulder Test, Disability of Arm, Shoulder, Hand, and Constant scores) were better when an associated stabilisation procedure had been performed rather than reduction alone (p = 0.05, p = 0.04 and p = 0.07, respectively).

We recommend meticulous pre-operative clinical assessment with CT scans. In sternoclavicular dislocation managed within the first 48 hours and with no sign of mediastinal complication, a closed reduction can be attempted, although this was unsuccessful in half of our cases. A control CT scan is mandatory. In all other cases, and particularly if epiphyseal disruption is suspected, we recommend open reduction with a stabilisation procedure by costaclavicular cerclage or tenodesis. The use of a Kirschner wire should be avoided.

Treatment of advanced Kienbock’s disease is challenging, and controversial. Palliative procedures should be chosen.

The goal of this study was to analyse the results of scaphocapitate arthrodesis with lunarectomy in advanced cases. Fourteen consecutive wrists in 13 patients were re-examined at a ranged follow-up of 31,7 months (range 3 to 103). Preoperative radiographs showed Lichtman stage 3a disease in 4 patients, stage 3b in 9 patients, and stage 4 in the last patient. Eight patients were women, and the involved wrist was the dominant in 8 cases. The age at operation averaged 36,6 years (range 24 to 55). Symptoms consisted in pain or pain with stiffness. Operative techniques consisted through a dorsal approach in excision of the dorsal interosseus nerve, lunarectomy, and scaphocapitate arthrodesis. Autologous bone graft was used in 8 cases, and osteosynthesis used K wires or staples. The wrists were immobilized in arm cast during 6 weeks, and rehabilitation was started. Postoperatively, one patient developed a complex regional pain syndrome.

At longest follow-up, patients were very satisfied in 8 cases, satisfied in 4, and poorly or not satisfied in 2 cases. Three wrists were painless, and only one wrist had no improvement. One wrist had no improvement. All the employed patients returned to their original work. Mean wrist motion increased slightly. Flexion increased from 33.3 to 33.9°, extension from 39.6 to 39.3°, ulnar deviation from 20 to 23.7°, and radial deviation from 18.8 to 17°. The arc of motion was useful (Flexion- Extension: 73.7° range, Pronation-Supination: 172.7°) Grip strength increased and reached 64.5% of the controlateral wrist. The mean gain was 5.6 Kg (+199%). The improvement was slow and very progressive over one year. On radiographs the arthrodeseses were consolidated in all cases, but the union seemed partial but asymptomatic in two wrists. Correction of scaphoid in flexion was difficult to obtain. No arthritis or degenerative changes were observed, but the distal radial epiphysis seemed to be reshuffled to the new joint and articular surfaces, with progressive disappearance of the radial lunar notch

Scaphocapitate arthrodesis associated with lunarectomy allows getting a painful and functional wrist. This simple procedure theoretically decreases load across the radiolunate joint, prevents further carpal collapse, and stabilizes the midcarpal joint.

Purpose of the study: Glenohumeral dysplasia is an uncommon cause of degenerative disease of the shoulder joint. In this context, arthroplasty is a therapeutic challenge due to the bony deformations.

Material and methods: Between 1998 and 2004, simple humeral prostheses were implanted in eight shoulders (seven patients, two men and five women, mean age 49.5 years). There was no procedure on the glenoid cavity. A Neer II was used for four shoulders (two dysplasic cases with short 63 mm stems) and a Neer III for four shoulders.

Results: At mean follow-up of 4.5 years (maximum 7 yers) the Neer outcome was satisfactory for five patients and non-satisfactory for two. Five of the seven patients were satisfied with their operation. The Constant scores improved: from 3.5 to 11.8 for pain, 9.8 to 16.6 for activity, and 13.8 to 24.4 for active mobility. Active anterior elevation was 114° on average, external rotation 25°, and internal rotation at level L3. The overall constant score was 52.8 points with a weighted score of 43%. Radiographically, there were no lucent lines around the humeral implant. Anterior dislocation occurred in one shoulder six months after the initial operation. Capsuloligament revision was performed but the implant was left in place. For one other shoulder, secondary rotator cuff tears limited the function outcome, but the prosthesis was not revised.

Discussion and conclusion: The results were average, but did allow our patients to resume nearly normal activity without pain. Looking at the failures in this small series suggests that the status of the rotator cuff is the main prognostic factor. Neither glenoid deformation nor the lack of replacement appeared to have an effect on the final outcome. Deformation of the proximal end of the humerus may require use of a shorter stem which should be available at the time of the operation.

Purpose of the study: The proximal humerus is a common localization for solitary endchondroma. Levy (Clin Orthop2004, 431) emphasized the frequency of associated muscle and tendon disease. Treatment is generally curettage-autograft filling. Use of calcium phosphate bone substitute has been validated (A. Uchida et al. J Bone Joint Surg (Br) 90, F. Gouin Rev Chir Orthop 95, R. Mirzayan J Bone Joint Surg (Am) 2001). This retrospective analysis was conducted to determine the signs and symptoms and report the results of surgical treatment obtained in a consecutive series of 15 patients with metaphyseal enchondroma treated in the same unit.

Material and methods: This series included twelve women and three men, mean age 48.2 years (range 38–73). All complained of pain. Two also had signs of calcification and six presented a cuff tendinopathy. Eight had had one or more joint injections. On average, the enchondromas measured 3.1 cm on the ap view and 3.6 cm on the lateral view. Magnetic resonance imaging (MRI) demonstrated the presence of a subacromial effusion in 13/16 shoulders, supraspinatus tendinopathy in six, calcifications in three, and acromioclavicular arthropathy in three. Curettage was followed by filling with biphased tricalcium phosphate (SBM, Lourdes) associated in nine shoulders with acromioplasty-bursectomy and in two with resection of a calcification.

Results: There were no postoperative complications. Mean follow-up was six months. All patients recovered joint motion, seven were pain free, six complained of pain at exercise and two had episodic pain. There were no local signs of substitute intolerance. Follow-up was greater than one year in 12 patients and greater than two years in eight: seven shoulders were pain free, three presented pain at exercise, and two required analgesic drugs. Radiographically, the limit between the bone substitute and the cancellous bone was imprecise; the bone substitute could not be readily visualized in four shoulders, had faded out in three, and was visible in five.

Discussion: The association of enchondroma and a rotator cuff pathology is common suggesting the tumor could affect disease expression. Imaging provides strong arguments favoring a benign disease. Use of bone substitute for filling is reliable and avoids the need for an iliac graft.

Conclusion: A fortuitously discovered or painful enchondroma of the humerus should be treated by curettage-filling with bone substitute as soon as the nature of the tumor has been clearly identified and/or strong uptake on scintigraphy visualized. This is a supplementary operative argument suggesting an associated cuff pathology.

Purpose of the study: Elbow dislocation is a frequent traumatic injury. Management is well described. An associated vascular lesion is exceptional, but must be searched for systematically. We report a short series and describe our therapeutic strategy for these complicated dislocations.

Material and methods: Between 1999 and 2004, our emergency unit cared for 357 cases of elbow dislocation. For six, injury to the brachial artery was present. This series included four men and one woman, mean age 34.7 years. The causal trauma was a traffic accident for four, and a fall four two. The dislocation was open in three. The radial pulse could not be palpated in any of the patients but blood supply to the hand persisted in five. There was a clinically detected neurological deficit in three. After obtaining the necessary x-rays, the elbows were reduced in the emergency room. The radial pulse remained impalpable in all patients and arteriography was performed and revealed a rupture of the brachial artery in five and an arterial spasm in one. Vascular repair was undertaken in all six cases using an reversed venous graft. The elbow was stabilized with an external fixator in three patients. For the others, the elbow was immobilized for 21 days on average before remobilization.

Results: AT 23 months follow-up, the overall outcome has been average with a Mayo clinic score of 69.2 points. Only four elbows were functional. Only one patient had a pain free elbow. Stiff joint was the most frequent functional impairment: mean flexion was 111.7° with a 41.7° extension deficit. The blood supply to the hand was correct in all cases, but one of the graft bridges became obstructed by a thrombus, the distal vascularization being supplied by the collateral circulation. The initial neurological lesions recovered partially.

Discussion: Elbow dislocation with vascular injury is exceptional but must be systematically detected. Emergency management associates reduction of the dislocation, a vascular work-up and rapid surgical management of the elbow, using an articulated external fixator when necessary, to limit as much as possible posttraumatic stiffness.

Purpose of the study: Locked centromedullary nailing (LCMN) has become the gold standard treatment for fractures of the femur (I. Kempf, Chirurgie 91 ; 117 : 478 / Borel R.C.O. 93 ; 79,553 / Wolinsky J. trauma 99, 46 : 382). Nevertheless, the SOFCOT 2004 round table emphasized the frequency of complications related to inappropriate material and techniques. The series studied had several biases: multicentric recruitment, materials with different designs, high percentage of patients lost to follow-up. In order to overcome these shortcomings we reviewed retrospectively a consecutive series of LCMN performed in a single center from 2001 to 2002, attempting to be as exhaustive as possible.

Material and methods: The study group included 78 patients (81 LCMN) aged 30 years on average (range 16–87 years) with male predominance (69%). A large proportion of patients were traffic accident victims (44% two-wheel vehicles, 42% four-wheel vehicles). The fracture was open in 8% and 65% of patients had multiple fractures (11% floating knees, 23% multiple trauma). The fractures were simple (43%), wedge (47%) and comminutive (10%). Time to operation was 7.4 hr on average for 83% of patients. Mean reaming was 12 mm (range 11–14 mm). An 11-mm (range 10–13 mm) static Grosse and Kempf (Stryker) nail was used in all patients. Intraoperative complications occurred in 8% of cases with no effect on bone healing.

Results: Three patients died from severe head trauma. Five patients were lost to follow-up. Written follow-up data were available for six patients and 64 patients were reviewed clinically. Among the 70 fractures with known outcome, four had not healed (with two screw failures and one nail failure). Knee motion was normal in all patients. Anteroposterior and lateral alignment was normal (±5°) in 94% with no leg length discrepancy (< 10 mm)in 87%. The nail was withdrawn in 84% of patients and the withdrawal procedure was complicated in three cases (hematoma, screw failure). Mean hospital stay for single-fracture patients was 9.7 days for nailing and 2.2 days for nail removal.

Discussion: LCMN is a reliable technique which provides constant clinical results when applied with rigorous technique. The logistics is resource intensive. Nonunion can be revised with the same method. A new nailing with second reaming should be performed early in the event of late healing.

Purpose: Non-traumatic osteonecrosis of the humeral head is an uncommon condition. Arthroplasty remains the treatment of choice when the head has lost its spherical shape. The purpose of this work was to assess clinical and radiological results in a monocentric consecutive series of 19 shoulders.

Material and methods: Twelve men and five women, mean age 56 years were treated for humeral head osteonecrosis with a shoulder prosthesis. Seven patients had quadripolar necrosis: two had four prostheses (2 shoulder + 2 hip), three had three prostheses (1 shoulder + 2 hip), and two had two prostheses (1 shoulder + 1 hip). Osteonecrosis was idiopathic in six cases, related to corticosteroid treatment in ten, radiotherapy in two, and Gaucher disease in one. The Arlet and Ficat classification showed stage II=3, stage IV=13 and stage V=3. There were rotator cuff tears in two patients. Fourteen simple humeral prostheses and five total shoulder prostheses were implanted.

Results: At mean seven years follow-up (2–12), the Neer classification showed excellent outcome in seven shoulders, satisfactory outcome in nine, and unsatisfactory outcome in three. Eighty-nine percent of the patients were satisfied. The Constant pain score improved from 1.5 points to 11.5 points, the activity score from 7.2 to 14.6, and motion from 15 to 27. Active anterior flexion was 120°, external rotation 34°, internal rotation at L3. The rough Constant score was 58 and the weighted score 78%. There were no lucent lines around the humeral implants, but a complete line was present around two glenoid implants which were radiographically loosened. These two shoulders presented glenoiditis with glenoid wear. No surgical revisions have been performed to date.

Discussion: Shoulder prosthesis has given satisfactory results for osteonecrosis of the humeral head with resolution of pain in 80% of patients. Shoulder motion remains limited in relation with the often significant preoperative stiffness. Results have been better in patients with less advanced disease preoperatively and preserved motion. In our series, poor results were found in patients whose osteonecrosis was radiation-related.

Purpose: Finite element analysis can be used to assess the behaviour of loaded structures. We used this method to evaluate the influence of glenoid implant design on the behaviour of an osteoarthritic scapula.

Material and methods: A 76-year-old female patient scheduled for a shoulder prosthesis underwent preoperative computed tomography of the osteoarthritic shoulder. Two polyethylene implants were evaluated: one with a triangular stem and the same prosthesis with three studs. 3D reconstruction of the glenoid cavity with the implants was then obtained and processed with the finite elements method. Three loadings were applied to the model: centred loading to reproduce the case of an ideally stable prosthesis with a normal tendinomuscular environment and excentred loading to simulate a deficient rotator cuff or prosthesis instability.

Results: With centred loading, stress remained low, to the order of 7 MPa, at the stem-glenoid cavity interface. Excentered loading produced peak stress on the borders of the glenoid implants, directly under the loading zone and at the tip of the stem, at the bone-cement interface, reaching 20 MPa. The implant tended to bend in the anteroposterior direction producing strong shear forces on the posterior part of the glenoid cavity. These forces caused micromovement at the cement-bone interface. There was no significant difference between the stem and stud implants.

Discussion: Eccentric loading of the glenoid implant appears to have a negative effect on long-term survival, the stress reaching levels greater than the values of cement fatigue fracture. Peak stress was situated on the posterior border of the cement layer due to the small space available between the implant the cortical bone in the posterior part of the osteoarthritic scapula. In this situation, the tip of the stem or the studs tend to come into contact with the posterior cortical of the scapula. When inserting a total shoulder prosthesis, it appears to be more important to keep in mind the geometry and the mechanical properties of the scapula than the implant design.

Introduction and purpose: Elbow arthroscopy (EA) has developed only recently and the main series have been published since the ‘80s. The present study reviews the experience gained with EA as well as the current indications of this technique in the Orthopaedic Surgery Department of the Purpan Hospital in Toulouse.

Materials and methods: This is a retrospective study on 23 patients (5 females and 17 males) with a mean age of 39.5 years (range: 17–68 years) operated on between 1993 and 2003. A record was kept of epidemiological variables, the indication, operative findings and the results, with a mean follow-up of 8 months (range: 1–36 months).

Results: Indication was diagnostic in 5 cases, diagnostic and therapeutic in 5 cases and diagnostic and therapeutic in 13 cases. A mini-procedure was performed in 3 cases to supplement the surgery of the posterior compartment. In 4 cases an external arthrotomy was carried out in order to extract large-size foreign bodies. The mean gain in ROM was 26°, with a mean gain in flexion of 5° and a mean gain in extension of 20.5°. During follow-up, 5 patients referred a persistence of pain. The best results regarding pain relief were obtained in patients with osteoarthritis. There was only one neurological complication, which was only transient.

Discussion and conclusions: We consider the elbow arhtroscopy to be a safe procedure whose mail indication is the extraction of foreign bodies. It is to be expected that the gradual improvement of the surgical technique will open the door to an increase in its indications.

Purpose: The results of coracoid blocks for the treatment of anterior shoulder instability are satisfactory (SOFCOT 1991 and 1999). Little work has been devoted to complications of this operation. We report our results after surgical revision in a consecutive series of seventeen patients.

Material and methods: Fourteen men and three women, mean age 34 years, required a second interention after anterior coracoid block: for recurent instability in ten cases and for painful stiff shoulder in seven. Radiographic assessment demonstrated a conflict between the block and/or the screw with the humeral head in 13 cases and signs of joint degeneration in three. The block was malpositioned in eight shoulders. The stabilisation procedure (Bankart ± capsuloplasty) was performed for these unstable shoulders with debridement and removal of the screw and or the block for painful stiff shoulders. The subscapular tendon was normal preoperatively in two shoulders, fibrous or thin in eleven and torn in one. The time from the first operation to revision was eleven years on the average.

Results: At mean follow-up of 21 months, the patients were assessed with the Duplay score. Results were good or excellent for eleven patients (70% for stabilised unstable shoulders and 57% for debrided painful stiff shoulders), fair for four and poor for two. Clinical assessment of the subscapular demonstrated a deficiency in ten shoulders. The force of internal rotation of the operated shoulder was 3.3 kg less than for the controlateral shoulder. Computed tomography demonstrated significant fatty degeneration of the subscapular in four patients. Glenohumeral joint degeneration was observed in nine shoulders. The most significant prognostic factor for final outcome was the number of prior interventions (p< 0.01).

Discussion: The result of revision surgery after coarcoid block depends on the clinical presentation. While the results for painful stiff shoulders remained very limited due to frequent intra-articular lesions, adjunction of a capsuloplasty with or without reinsertion of the glenoid rim yielded satsifactory results in more than two-thrids of the unstable shoulders. Involvement of the subscapular muscle appears to be related to multiple interventions in these shoulders, as well as to the deleterious effect of the block (Picard 1998, Glasson 1999) and continues to be the crucial prognostic factor for final outcome.

Purpose: External fixation has restricted indications in fractures of the femur, particularly in the distal portion. Between 1986 to December 2001 we used external fixation for 21 first-intention treatments of metaphyseal epiphyseal distal femur fractures. This retrospective study was designed to detail the contribution of this type of fixation.

Material and methods: The series included 14 men and six women (one bilateral case), mean age 33 years (range 17–83). All patients were victims of high-energy trauma. Twelve had multiple injuries (mean ISS 20) and 16 had multiple fractures including ten floating knees. According to the Gustilo classification, the 20 open injuries were one type 1, five type II, fourteen type III including two IIIC with rupture of the femoral artery. Three patients had burns or degloving injury of the thigh. An exclusive femoro-femur fixation was used with a dynamic axial fixator associated with complementary epiphyseal screws in eight cases. The AO classification ws six metaphyseal injuries (4 C2, 7C22 and 3 C23). Associated procedures included two vessel repairs, two rectus dorsi flaps, and four modifications of the fixator or new reduction.

Results: One patient died from mulitple injuries. Two required amputation for failed vascular repair and free flap. Eight patients achieved bone healing with the fixator alone including two who had an autologous graft. Mean time to healing was 10 months (5–14). One patient developed secondary fracture at eight months treated successfully with retrograde nailing. The knee had to be mobilised in four cases and arthrolysis was necessary in three. For ten cases, the external fixator was replaced voluntarily with centromedularly nailing (n=2, one supracondylar and one Grosse Kempf), or plate fixation (n=8) associated with autologous graft in four (three fibular transfers and one iliac graft). These two operative times were consecutive in seven cases and separated by a period of traction in three. The two nailings and the five plate fixations healed in a mean eight months (5–10). Three plate fixations failed: two aseptic nonunions (prosthesis revision and arthrodesis) and one suppuration currently under treatment. At minimum follow-up of 18 months, 15 patients had a known clinical result with bone healing achieved: mean active flexion was 81° (50–120°). Only one patient had deficient extension (10°). Nine patients had achieved anatomic alignment in both the frontal and sagittal planes; three presented recurvatum of 5–10° and three had a frontal deviation less than 10°.

Discussion: This experience illustrates the difficulty in correctly reducing femoral alignment while maintaining active knee mobility. This series points out the risk of infection in case of secondary osteosynthesis. External fixation should be reserved for exceptional indications: rupture of the vascular trunk, major cutaneous injury, or a temporary solution in the case of multiple injuries before rapid osteosynthesis to achieve a stable fixation.

Purpose: Reaming is classically contraindicated for open leg fractures. For certain authors, reaming can favour bone healing without increasing the risk of infection (Court-Brown JBJS 90B and 91B, Wiss Coor 95). The aim of this retrospective analysis of patients treated in a single centre was to validate these notions and determine the role of locked centromedullary nailing (LN) with reaming for the treatment of open leg fractures.

Material and methods: Between 1989 and June 2000, 141 open leg fractures were fixed with locked centromedullary nailing without reaming in 103 men and 38 women, mean age 34 years, who were mainly accident victims (2-wheel vehicles 43%, 4-wheel vehicles 22%). Multiple trauma was present in 18.7% of the cases and multiple fractures in 28%. Skin wounds were (Gustilo classification): type I 81 (57%), type II 38 (27%), type IIIA 14, and type IIIB 8. There was a simple fracture in 50% of the cases, a wedge fracture in 32%, and comminution in 18% with bifocal fractures in 10 cases. Osteosynthesis was performed within a mean 5.5 hours (2–18) and deferred in six cases. The Grosse and Kempf nail was used in all cases with reaming (man 11). Static locking was used in 88% of the cases. type I, II and IIA skin wounds were sutured after debridement. Three aponeurotomies were performed as preventive measures. Type IIIB wounds were treated by early plasty. A brief antibiotic prophylaxis was given in all cases.

Results: There was one aggravation of the comminution, two dismantelings subsequent to unauthorised weight-bearing, three compartment syndromes and one lateral sciatic popliteal paralysis. Two patients died from their multiple injuries. Four patients developed infection: two healed without removing the nail, one was amputated (free flap failure). One patient consulted another unit. Ten patients who were not residents of our area were lost to follow-up. Dynamisation was performed in 31 patients (25.6%) at a mean 4.4 months. Four patients with delayed healing cured after a new nailing with secondary reaming. Delay to bone healing was related to the type of fracture (p < 0.01): 4.2 months for type A (AO classification), 5.2 months for type B and 5.9 months for type C. Bone healing was correlated with Gustilo type (p < 0.05): 4.5 months for types I, 4.6 months for type II, 5.8 months for types III. Six patients developed nonunion: four were revised with success after a new nailing and secondary reaming (two lost to follow-up). Delayed healing and non-union were related to type of fracture (A = 3.8%, B = 15.6%, C = 18%) and soft tissue damage (Gustilo I: 4.1%; II: 10.7%; III: 15.8%).

Discussion conclusion: Locked centromedullary nailing with reaming is appropriate when the skin wound is minimal; dynamisation and/or replacement of the nail with secondary reaming should be discussed early in case of delayed healing.

Purpose: We report a series of 16 GUEPAR total elbow prostheses implanted in a single centre.

Material and methods: Between 1988 and 1996, sixteen GUEPAR prostheses were implanted in 13 patients (three bilateral implantations). There were 11 women and two men, mean age 61 years (51–81). Twelve patients (14 elbows) had rheumatoid polyarthritis and one patient (two elbows) had post-traumatic degenerative disease. The V transtricepital approach was used in 15 cases and the Bryan-Morrey approach in one. Postoperatively, the elbows were immobilised at 45° flexion for the normal period (18 days) followed by active mobilisation. Results were analysed with the Mayo Clinic score. The radiographs were examined in search for lucent lines and signs of loosening and prosthetic instability.

Results: At a mean follow-up of four years (2–12), the mean Mayo Clinic score had improved from 33 to 75 points (45–100). Eleven elbows were pain free at last follow-up. Extension and flexion progressed 22° giving a postoperative amplitude of 34° to 129°. Pronation supination progressed by 15° giving a 154° rotation amplitude. The function score improved from 6 to 18 points. Seven of the sixteen elbows achieved normal function. Outcome was excellent for seven elbows, good for one, fair for three and poor for five. In two elbows, instability required changing the ulnar implant. There were four implant loosenings that required revision at 24, 36 ,36 and 48 months after the initial implantation. The radiographic analysis demonstrated a complete lucent line around the humeral and ulnar implant in one case, around the ulnar implant in one case. There were two peroperative fractures of the humerus and on postoperative fracture due to a fall. Ulnar paresthesia was observed in two cases requiring secondary neurolysis in one. There were no infections or secondary injury to the triceps.

Discussion: The GUEPAR prosthesis is a non-constrained prosthesis essentially indicated for rheumatoid polyarthritis. If the intrinsic stability is lost, the implant is contraindicated if there is loss of bone stock or if the instability is major. In selected cases, a generally painless elbow with recovery of the functional amplitude can be achieved with this prosthesis. Nevertheless, the presence of four early loosenings in our series as well as two instabilities suggest this implant should be abandoned in favour of a semi-constrained implant.