[GUEPAR I total elbow arthroplasty in rheumatoid arthritis: 19 implants followed an average of 67 months]. / Prothèse totale de coude GUEPAR I dans la polyarthrite rhumatoïde: 19 cas avec un recul moyen de 67 mois.

INTRODUCTION: The GUEPAR I total elbow arthroplasty is a nonconstrained implant used since 1985. Only one multicenter study has reported the mid-term results of this implant in rheumatoid arthritis. We presented a monocentric retrospective study evaluating the results of 19 GUEPAR I total elbow arthroplasty in rheumatoid arthritis with a mean follow-up of 67 months. MATERIALS AND METHODS: Between 1988 and 1996, 19 GUEPAR I total elbow arthroplasties have been performed on 16 patients (3 bilateral). There were 15 women and one man, averaged age 58 years. Radiographically, the elbow was classified as stage IIIA in 8 cases, and stage IIIB in 11 cases, according to the Mayo Clinic classification. A triceps splitting approach with tendon reflection was performed in all cases. A postoperative immobilization at 45 degrees extension was used for all patients during 21 days averaged, and active mobilization was then started. RESULTS: At 67 months averaged follow-up (range, 2 to 12 years) the Mayo Elbow score improved from 36 to 75 points. The overall results were considered as excellent for 8, good for 5, fair for 2, and poor for 4. Nine elbows were totally painfree and six had minimum pain. Postoperative arc of motion reached 36 to 126 degrees in extension-flexion and 147 degrees in rotation. Eleven out of 19 elbows had a normal functional score. Two elbows dislocated and two others had a valgus instability lower than 10 degrees. There were thirteen complications affecting 11 of the 19 elbows (68%), and six of these eleven elbows had a revision procedure (31%): 3 peroperative medial column fractures, one postoperative medial column fracture which has been fixed, two elbow dislocated with one ulnar component revision, and 3 loosed implants which has been revised. There were persistent ulnar paresthesiae in two cases with a secondary neurolysis performed in one. Finally two infections developed 6 years after the initial procedure, one superficial, and one deep, which lead to removal of the total elbow arthroplasty. DISCUSSION-CONCLUSION: The GUEPAR I total elbow arthroplasty is a nonconstrained implant indicated essentially in rheumatoid arthritis. Without intrinsic stability this implant must be contraindicated in front of bone stock deficiency, or chronic instability of the elbow. In selected cases the GUEPAR I total elbow arthroplasty offers a painfree elbow with a functional range of motion.

[Risks and results after simultaneous intramedullary nailing in bilateral femoral fractures: a retrospective study of 40 cases]. / Risques et résultats de l'enclouage simultané des fractures bifémorales.

PURPOSE OF THE STUDY: A retrospective series of 40 patients who underwent simultaneous intramedullary nailings for bilateral femoral shaft fractures was analyzed. The aim of our study was to verify that simultaneous nailing without reaming does not increased risk of fat embolism and to assess clinical and radiological outcome. MATERIAL AND METHOD: This series included 27 men and 13 women, mean age 27.8 years, who underwent first intention intramedullary nailing between 1986 and February 1999. Thirty-two patients had multiple fractures. Mean ISS was 23 (range 9 to 59). Among the 80 femoral shaft fractures, 15 were open fractures, 3 were associated with sciatic paralysis, and 4 were complicated by an interruption of the femoral vessels. The AO classification was: type A=44; type B=25; type C=11. Mean delay to simultaneous centromedullary nailing was 3. 8 days: surgery was performed on the day of arrival for 25 patients. General anesthesia was used in all cases with respiratory assistance (FIO(2) =50 to 100 p. 100). Mean nail diameter was 11.6 (range 10-14). Gurd criteria and PaO(2) were followed to assess pulmonary function. Clinical and radiological outcome was assessed using the modified Thorensen criteria. RESULTS: Preoperatively, PaO(2) was< 87 mmHg in 8 patients. Four of these patients showed a discrete drop off and three improved well above the normal level. Only one patient experienced an important decrease but did not develop respiratory distress. Among the 32 patients with a normal level preoperatively, PaO(2) remained in the normal range in 18, fell to a limit level but below 87 mmHg in 4, and showed a substantial drop off of 46 to 172 mmHg in 10. Two of these 10 patients developed respiratory distress due to fat embolism which was fatal in one case. One other patient died in the immediate postoperative period of an undetermined cause. All of the other patients recovered normal gas levels within a few hours or days. There were four cases of phlebitis, including one with pulmonary embolism, one case of respiratory distress by pulmonary superinfection, and one case of septicemia. Both femoral fracture sites became infected in one patient. Malunion occurred in two cases. Two vascular repairs of the femoropopliteal axis were unsuccessful, leading to above knee amputations. Thirty-four patients have been examined after a minimal 12 months follow-up (mean 30 months). Outcome was excellent for 48 femurs, good for 10 and fair for 10. DISCUSSION: This continuous series of simultaneous bilateral femoral shaft intramedullary nailings appears to be the only such report to date. The clinical and radiological outcomes were comparable with those achieved in one-side femoral fractures. The risk of fat embolism is inevitable after long bone fractures. Many factors favoring the risk are recognized, the most important being delay to fixation. Reaming creates excessive pressure in the medullary canal and could thus contribute to the risk. The presence of an associated chest trauma is not a formal contraindication if effective hematosis is preserved as evidenced by the blood gases. CONCLUSION: Simultaneous nailing of bilateral femoral shaft fractures can be performed if blood gases remain acceptable and minimal reaming is used.