Cementless and locked prosthesis for the treatment of 3-part and 4-part proximal humerus fractures: prospective clinical evaluation of hemi- and reverse arthroplasty.

INTRODUCTION: Cemented stem remains the gold standard for prosthesis in trauma. The purpose of this study was to evaluate the functional and radiological outcomes of a cementless, trauma-specific locked stem (hemi and reverse) for 3- and 4-part proximal humeral fractures. MATERIALS AND METHODS: One hundred and thirty-four 3- and 4-part fractures have been treated by locked stem, 69 with hemiarthroplasty [mean age 68 years (50-90)] and 65 with reversed [mean age 78 years (66-91)]. The length of the stem was 15 cm with a proximal coating of HA automatic locking system (two screws) and four different diameters. Preliminary cadaver study allowed us to validate the system (22 shoulders, no injuries of nerves, locking system efficient). RESULTS: In the group of hemi, Constant score with ponderation reached 72 (11-120) and QDash 31.2 (4.5-77.27) with a mean FU of 25 months (6-96). In the group of reversed, Constant score with ponderation reached 77.6 (28.8-119) and QDash 36.2 (2-84) with a mean FU of 15 months (6-41). Specific complications due to locking system reached 3% but without reoperation. Other complications were capsulitis and infection. DISCUSSION: In this population of elderly patient, new fall with periprosthetic fracture or infection led the surgeon to remove the stem. At shoulder level, the removal of a cemented stem remains a highly demanding procedure with sometimes bad functional results and elevated level of complications. This series is the first one of locked stem without significant complications. Locked stem remains a new but logical tool in trauma.

Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: a comparative study of 40 cases.

INTRODUCTION: As population ages, the number of fractures of the proximal humerus in still-active patients is increasing. For three- or four-parts displaced fractures in which replacement is indicated, hemiarthroplasty with tuberosity reattachment remains the reference treatment; this technique, however, can lead to catastrophic functional results due to nonunion or tuberosity migration. The present study compared short-term functional results for reverse prosthesis and hemiarthroplasty in complex fractures of the proximal humerus. HYPOTHESIS: In selected complex proximal humerus fractures, the reverse shoulder arthroplasties is a superior treatment option. PATIENTS AND METHODS: Forty patients were treated by shoulder replacement for three- or four-part displaced fractures of the proximal humerus between 1996 and 2004. Twenty-one had a hemiarthroplasty and 19 were treated by reverse prosthesis. All patients of both groups were reviewed retrospectively by an independent observer. Joint amplitude and Constant score were measured; quality of life was assessed by DASH score. Standard X-ray assessment comprised frontal imaging in three rotation positions and Lamy's incidence. RESULTS: In the hemiarthroplasty group, 17 patients, mean age 74 years (range: 49-95), were followed up for a mean 16.5 months (6-55). In the reverse prosthesis group, 16 patients, mean age 74 years (range: 58-84), were followed up for a mean 12.4 months (6-18). The reverse prosthesis group showed better results in terms of abduction (mean=91 degrees versus 60 degrees), anterior elevation (mean=97.5 degrees versus 53.5 degrees) and Constant score (mean=53 versus 39). Rotation was better in the hemiarthroplasty group (external rotation, 13.5 degrees versus 9 degrees ; internal rotation, 54.6 degrees versus 31 degrees). DASH scores were identical in both groups. X-ray showed three abnormal tuberosity fixations in the hemiarthroplasty group and 15 glenoid notches in the reverse arthroplasty group. DISCUSSION: In three- or four-part displaced proximal humerus fracture, arthroplasty does not ensure recovery of pretrauma shoulder function. Management is therefore to be decided in terms of outcome predictability and rapid recovery of daily comfort for elderly patients. Hemiarthroplasty can provide good functional results, but depends on tuberosity union quality and this often necessitates a prolonged immobilization. Reverse prostheses provide reliable, rapid and predictable results in terms of abduction, anterior elevation and pain relief, but impaired rotation; this impacts quality of life and long-term implant durability (glenoid notching). Reverse prostheses should thus prove advantageous in the treatment of complex fractures of the proximal humerus if these two drawbacks can be resolved and at present seem indicated on condition that the patient is no younger than 70 years of age.

[Functional and sonographic shoulder assessment after Seidel nailing: a retrospective study of 29 cases]. / Evaluation fonctionnelle et échographique de l'épaule après enclouage de Seidel.

PURPOSE OF THE STUDY: Centromedullary nailing with a Seidel nail is a validated treatment for humeral shaft fractures which some teams have abandoned due to the injury caused to the rotator muscles. The purpose of this study is to assess shoulder function (Constant and DASH) after nailing procedures and to analyze sonographic findings. MATERIAL AND METHODS: Twenty-nine patients who underwent Seidel nailing between 1996 and 2002 were reviewed by an independent operator at 36 months follow-up on average (range 11-84 months). The sex-ratio was 1.64. Mean age at surgery was 41.5 years (range 17-81 years). The dominant side was involved in 17 cases. Fracture was caused by a traffic accident in 13 cases, a fall in 12, and a blunt injury in 4. The fracture was situated in the mid third of the shaft in 19 cases, the upper third in 3, the mid and lower third in 3 and mid and upper third in 3. Mean delay before surgery was 2.4 days. Initial complications were medioulnar palsy (n=1), complete brachial palsy (n=1), partial brachial palsy (n=1). There was one open Cauchoix I fracture. RESULTS: Bone healing was achieved in 27/29 patients at 3.5 months on average. Revision was required in nine patients. The Constant score was 69.1 (86.9% contralateral). The weighted Constant score was 81.7 and the DASH was 25. The Constant score was significantly better in patients aged less than 50 years and with transverse fractures. Sub-acromial space narrowing was observed in six patients at follow-up and only 9/28 sonographic examinations (32%) were normal; most shoulders presented transient healing lesions. DISCUSSION: This series was comparable with others regarding patient satisfaction, bone healing and complications, but was less satisfactory for the Constant score and time to healing. We have found that using a subjective function score (DASH) with an objective score (Constant) enables a better assessment of shoulder function. Like Gaullier, we consider that after cuff healing, anterograde nailing does not compromise shoulder function despite the injuries observed sonographically.

[Bone and soft tissue loss of the proximal interphalangeal joint of the long fingers: emergency treatment with a Swanson implant: prospective study of ten patients with mean 2.7 year follow-up]. / Perte de substance ostéo-articulaire de l'IPP des doigts longs: traitement en urgence par implant de Swanson: étude prospective de 10 cas avec 2,7 ans de recul moyen.

PURPOSE OF THE STUDY: Injury of the proximal interphalangeal joint (PIP) with loss of bone and soft tissue (joint surface, tendon, skin cover) can compromise finger vascularization. Fusion or amputation is often proposed. We report our experience with another solution, emergency implantation of the Swanson implant. MATERIAL AND METHODS: Thirteen patients, mean age 47.4 years (range 18-76) underwent emergency surgery between 1997 and 2003. In twelve patients, the finger injury occurred when working with wood. For ten of the thirteen patients, the injury occurred during recreational activity. The index was involved when only one ray was injured. The thumb was spared in all patients. Joint tissue was lost in all patients. The head of P1 was injured in all cases creating a situation incompatible with fusion without loss of finger length. All patients underwent an emergency surgery for complete reconstruction of the PIP joint with Swanson implant, tendon reconstruction or suture, and skin cover performed during the same procedure. RESULTS: Ten patients, 16 implants, were reviewed at mean 2.7 years (range 1-6 years). Mean flexion reached 41.8 degrees (range 20-80 degrees). Maximal amplitude of flexion was achieved at one year and remained unchanged thereafter. There were no cases of infection, or secondary amputation. Two implant fractures were noted with no functional impact at six years. There were four cases of instability. DISCUSSION: Most reports in the literature concern composite blast or firearm injuries. Ours appears to be the first series involving injuries occurring while working with wood. Most of the lesions caused by the circular saw were tangential, damaging the dorsal aspect of several PIP joints. Classically, it would be logical to propose arthrodesis if the bone and cartilage loss is not excessive, but with the loss of joint motion provided by implants. Like Nagle, we propose emergency implantation of a Swanson prosthesis if soft tissue and tendon reconstruction can be achieved, avoiding amputation. Although the technique is relatively simple, implantation of a Swanson prosthesis implies certain prerequisites, particularly ligament repair and correct alignment. Oversized implants appear to be better. We did not have to perform any secondary arthrodesis.

[Osteocartilaginous autograft after proximal resection of the scaphoid for radioscaphoid osteoarthritis]. / Arthrose radioscaphoïdienne traitée par autogreffe ostéocartilagineuse après résection proximale du scaphoïde: technique et résultats d'une série préliminaire de 10 cas.

PURPOSE OF THE STUDY: Radioscaphoid osteoarthritis is usually a complication of scaphoid pseudarthrosis or chronic scapholunate disjunction. As an alternative to the classical surgical techniques used for this lesion, we propose a novel reconstruction method consisting In partial proximal resection of the scaphoid associated with interposition of a biological spacer composed of a osteocartilaginous rib graft. The purpose of this study was to present the technical aspects of this procedure and to report preliminary results in ten patients with radioscapular osteoarthritis treated between 1994 and 2001. MATERIAL AND METHODS: We performed a retrospective analysis of the ten patients who underwent surgery from 1994 to 2001 for early-stage radioscaphoid osteoarthritis associated with scaphoid osteoarthritis in eight and chronic scapholunate disjunction in two. The procedure consisted in partial resection of the proximal portion of the scaphoid and insertion of an osteocartilaginous autograft harvested from a rib. Outcome was based on the clinical results (pain, motion, grip force, activity) and patient satisfaction. Bone healing was measured with plain x-rays and vitality of the osteocartilaginous graft with MRI. RESULTS: Mean follow-up was 4.6 years. Clinical outcome was considered excellent or good in eight patients, fair in one and poor in one (graft dislocation). All patients were satisfied or very satisfied except one (one failure). Radiological healing was achieved at three months in nine patients. Four patients underwent an MRI examination at thirteen months which demonstrated, in all patients: no sign of necrosis, healing of the graft-scaphoid interface, and no bony metaplasia in the cartilage. DISCUSSION: Compared with partial carpal arthrodesis and resection of the first row of the carpus, this palliative technique can be used to reconstruct the proximal portion of the carpal scaphoid in young patients with early-stage radioscaphoid osteoarthritis. As for arthroplasty or scaphoid implants, our goal was to achieve a satisfactory scaphoid height using a biological spacer after resection of the proximal 3/4 of the bone. The results of this technique are encouraging but must be examined with precaution due to the small number of patients and the short follow-up to date.

[Unreconstructible radial head fracture: resection, implant of Swanson or prosthesis? Retrospective comparative study]. / Fracture de tête radiale non synthésable: résection, implant de Swanson ou prothèse? Etude rétrospective comparative.

Treatment of unreconstructible comminuted fractures of the radial head remains a therapeutic challenge. Thirty two patients sustained unreconstructible radial head fracture between 1969 and 1999 and have been treated by resection (16 patients), by Swanson implant (8 patients), or by Judet prosthesis (8 patients). The three groups of patients were reviewed clinically and radiologically by two surgeons not involved in their treatment. Functional outcomes of the elbow (Morrey scoring-SOO scoring system, instability, cubitus valgus) and involvement of the wrist (pain, grasp, RUD instability) were evaluated with a mean follow up of 15 years (6-27.7). Elbow or wrist arthritis, ulnar variance, and evolution of Swanson implants were evaluated on standard radiographs. The Judet prosthesis group was evaluated with DASH scoring. Half of the patients were male and 1/3 had a work-related injury. Regarding the following criteria, there was no significant difference between the resection and the Swanson group: Morrey scoring 77/100, SOO scoring 7.4/11, mean flexion was 130 degrees, mean deficient extension was 18 degrees, mean pronation 60 degrees, mean supination 67 degrees, grasp reached 90% of the controlateral side. Arthritis was noted with the same frequency at the elbow (87%), and wrist levels (66%) in each group. Ninety four percent (94%) of patients in the resection group and 89% in the Swanson group were satisfied. Excellent and good results were reported more frequently in the Swanson group (37% resection group, 51% Swanson group). In the resection group the following complications were significantly more frequent: ulnar nerve irritation (2 x), ulnar head dislocation (2 x), ulnar head instability (3 x), para articular ossification (5 x), ulnar variance positive in all cases (mean value 3.20 mm). In the Swanson group only two implants were found to be destroyed at follow-up. In the prosthesis group function and satisfaction were higher than the two other groups but with a shorter follow up. Excellent and good results were reported in 62.5% cases with a DASH scoring between 0 and 16.7. Comminuted fractures of the radial head treated by resection or Swanson implant are both followed by fair results (same functional scoring). Only the level of complications differs between groups: at elbow level for Swanson group, at wrist level for the resection group. Patients in the Swanson group were most frequently satisfied. Metal radial head implant is an attractive solution yielding good functional outcomes in recent reported limited series and in our personal experience, but with a very short follow-up.