Locking plate fixation versus antegrade nailing of 3- and 4-part proximal humerus fractures in patients without osteoporosis. Comparative retrospective study of 63 cases.

INTRODUCTION: There is no consensus on the treatment of proximal humeral fractures. The goal of the present retrospective observational study was to compare functional and radiological results and complications of internal fixation using locking plates versus antegrade nailing in the treatment of non-osteoporotic Neer classification 3- and 4-part fractures after a least 1 year of follow-up. MATERIAL AND METHODS: Internal fixation was performed in 67 fractures (1 bilateral): 35 by locking plate (1 lost to follow-up, 1 deceased) and 32 by intramedullary nailing (2 lost to follow-up) between January 1st, 2004 and December 31st, 2010. Thus, the study included 33 plates (21 3-part and 12 4-part fractures) and 30 nails (21 3-part and nine 4-part fractures). Final functional assessment was based on the Oxford, Constant, Relative Constant and QuickDASH scores and percentage of handicap. Radiological follow-up included immediate postoperative, 6 weeks, 3 months and 1 year AP and Lamy lateral views. All complications were recorded prospectively. RESULTS: Mean Oxford, Constant, Relative Constant and QuickDASH scores and percentage of disability for the plate and nail groups respectively were: 23.8 vs. 23.3, 59.7 vs. 60 6, 73.5 vs 79.3, 20.9 vs 21.0, 22.6 vs 22.6. Multivariate analysis did not show any significant difference in functional scores or quality of reduction: final unsatisfactory reduction on AP view, 30.3 vs. 36.7%; lateral view, 3.2 vs. 10.0%; greater tuberosity, 9.1 vs. 16.7%. Four-part fracture (P<0.05), frontal reduction defect at follow-up (P<0.05) or greater tuberosity defect (P>0.05) had negative impacts on functional scores. The complication rates corresponded to those in the literature and did not differ between the techniques (P=0.1901) except for three infections in the plate group. DISCUSSION-CONCLUSION: Internal fixation is the treatment of choice for 3- and 4-part fractures in non-osteoporotic patients. Although no difference was found in the present study between locking plate and intramedullary nailing, the former seems to be less well adapted and more aggressive. TYPE OF STUDY: Retrospective observational study. LEVEL OF EVIDENCE: Level 4.

[Optoelectronic gait analysis after metatarsophalangeal arthrodesis of the hallux: fifteen cases]. / Analyse opto-électronique de la marche après arthrodèse métatarso-phalangienne de l'hallux: à propos de 15 cas.

PURPOSE OF THE STUDY: Degeneration of the metatarsophalangeal joint of the hallux is a frequent secondary lesion of the first ray subsequent to hallux valgus. Different surgical techniques have been proposed for cure, including metatarsophalangeal arthrodesis. Joint fusion relieves pain but sacrifices joint motion. The purpose of this work was to assess changes observed in gait after metatarsophalangeal arthrodesis of the hallux using a three-dimensional optoelectronic system. MATERIAL AND METHODS: Gait analysis was performed with a Vicon 3D system with five cameras and two AMTI force platforms in twelve patients who had undergone metatarsophalangeal arthrodesis more than six months earlier. The kinetic and kinematic curves and ground reaction forces were analyzed. Changes in the gait cycle and any compensations observed in the talocrural and interphalangeal joints were noted in the three dimensions. Wilcoxon test for paired series was applied for the statistical analysis. RESULTS: The general gait parameters and kinetic and kinematic values were not modified (excepting a non-significant decline in maximal dorsiflexion of the ankle joint). There was a significant decrease in propulsion force in the anteroposterior and vertical planes, with significantly later heal lift-off and systematic displacement of ground reaction forces anterior to the metatarsophalangeal joint on the arthrodesis side. Reflectors positioned on the distal extremity of the hallux demonstrated that the essential part of compensation occurred at the level of the interphalangeal joint. DISCUSSION: Gait analysis after tibiotalar arthrodesis has been widely reported in the literature. The consequence of joint fusion on the rear foot and/or the torsion couple have also been studied. However, to our knowledge, there has been only one report using a different methodology devoted to metatarsophalaneal arthrodesis of the hallux. In this study, only step length and interphalangeal moment as well as ankle force were found to be decreased. Function of the interphalangeal joint was not assessed. The Vicon system enabled an adapted study of gait after metatarsophalangeal arthrodesis. This method offers several perspectives: study of the effect of the position of the arthrodesis in the sagittal plane on gait, changes over time in interphalangeal joint motion, or consequences of fusion on walking up and down stairs. CONCLUSION: Metatarsophalangeal arthrodesis of the hallux does not modify general gait parameters nor the kinetic and kinematic values. Compensation is achieved via the interphalangeal joint.

Do clinical presentation and pre-operative quality of life predict satisfaction with care after total hip or knee replacement?

We conducted a multicentre cohort study of 228 patients with osteoarthritis followed up after total hip or knee replacement. Quality of life and patient satisfaction were assessed by self-administered questionnaires. Patient satisfaction was the dependent variable in a multivariate linear regression model. Independent variables included sociodemographic factors, pre- and post-operative clinical characteristics and the pre-operative and post-discharge health-related quality of life. The mean age of the patients was 69 years (sd 9), and 43.8% were male. Pre- and postoperative clinical characteristics were not associated with satisfaction with health care. Only pre-operative bodily pain (p<0.01) and pre-operative social functioning (p<0.05) influenced patient satisfaction with care. The pre-operative health-related quality of life and patient characteristics have little effect on inpatient satisfaction with care. This suggests that the impact of the care process on satisfaction may be independent of observed and perceived initial patient-related characteristics.

Tuberculosis of the patella.

BACKGROUND: A rare case of patella tuberculosis in a 33-year-old man is presented. In the last two decades, tuberculosis has made a vigorous comeback, due mainly to large-scale migration of populations and the increasing number of immunosuppressed patients. Extrapulmonary tuberculosis accounts for less than 3% of cases, and sites like the patella are very rare. Fewer than 10 cases were found in the international literature. METHODS: A 33-year-old man presented in our department with a 9-month history of pain and swelling of the left knee. Tuberculosis of the patella was diagnosed after biological and radiological investigations. RESULTS: Imaging studies, especially MRI, are of great interest for the diagnosis and to assess the extent of tuberculosis. Histology of the curettage specimen is also required to reach a definitive diagnosis and develop an adapted management strategy (chemotherapy and rehabilitation). CONCLUSION: Diagnosis and treatment should be urgent, including surgical debridement and well-conducted antitubercular therapy to yield a satisfactory functional outcome.

Polydactyly of the foot. Literature review and case presentations.

Polydactyly is a fairly common congenital condition of the foot and is characterized literally by supernumerary toes (digit or metatarsal). The frequency of polydactyly varies widely among populations. It may be an isolated condition or part of a congenital syndrome. Polydactyly is generally classified into three major groups: medial ray (preaxial), central ray and lateral ray (postaxial). The duplication may appear at the distal and middle phalanges or at the whole digit and metatarsal. The complexity of the deformity ranges from a simple soft-tissue problem to a completely developed accessory ray. Careful clinical and radiographic evaluation should be made prior to treatment to achieve good functional and cosmetic results. Most cases are treated during childhood before walking age. Adult cases are more rare, and surgical management of the deformity is still debated. Nevertheless, surgery can be performed at any age as in our series with good results.

Beta-tricalcium phosphate ceramic as a bone substitute in orthopaedic surgery.

Synthetic beta-tricalcium phosphate ceramic (Biosorb, S.B.M., Lourdes, France) was used as a bone substitute in 110 patients whose mean age was 48 (14-83) years. There was a wide spectrum of indications, and the material was used alone in 86, combined with a corticocancellous bone autograft in 22, and combined with a corticocancellous allograft in two. The patients were assessed clinically and radiographically. Incorporation of the ceramic was excellent in 30, good in 51, and fair in 26. There were no poor results. In three patients the implanted material was removed because of infection. Incorporation was good or excellent in about 75% of all 110 patients. We consider beta-tricalcium phosphate ceramic to be the substitute of choice for medium-sized bone defects.

Modified shoelace technique for delayed primary closure of the thigh after acute compartment syndrome.

The authors report a case of acute compartment syndrome in the thigh in a 19-year-old man with multiple injuries including fracture of the femoral diaphysis. Decompressive fasciotomy was performed emergently. Complete progressive closure of the wound without split-thickness skin grafting was achieved using a modified shoelace technique: sutures were run inside wide drains placed in contact with the muscles and were then tightened over the skin. These drains enlarged the contact area between sutures and muscles, preventing damage to muscles.

Bilateral traumatic hip dislocation associated with sacro-iliac dislocation.

We report a rare injury in an 18-year-old woman who sustained posterior bilateral hip dislocation with sacro-iliac dislocation after a high energy motor vehicle accident. She was treated by closed reduction and skeletal traction. Bilateral traumatic hip dislocation is an uncommon occurrence. Rarer still is bilateral traumatic hip dislocation associated with sacro-iliac dislocation because it combines two different mechanisms of trauma. (Hip International 2002; 1: 47-9).

[Filling of bone defects with tricalcium phosphate beta in traumatology]. / Comblement des pertes de substance osseuse par le phosphate tricalcique beta en traumatologie.

AIM OF STUDY: Synthetic bone substitutes like calcium phosphate ceramics have been used in orthopaedic surgery for several years. The aim of this study was to assess the results of the use of tricalcium phosphate beta for filling bone defects in trauma cases. PATIENTS AND METHOD: beta tricalcium phosphate was used in 24 trauma cases. The GESTO classification (Association pour l'étude des Greffes et Substituts Tissulaires en Orthopédie) and a qualitative scale were used to estimate the integration. RESULTS: With a mean follow-up of 20 months, integration was excellent in 41.2%, good in 29.2% and moderate in 17.4%. No fibrous encapsulation was observed around the implants in any case. Sepsis occurred in 3 cases with open fractures. CONCLUSION: beta-Tricalcium phosphate seems in our experience to be an excellent bone substitute for filling bone defects in trauma cases.

Use of supercritical fluid extraction as a method of cleaning anterior cruciate ligament prostheses: in vitro and in vivo validation.

The process of supercritical fluid extraction (SFE) using carbon dioxide as the mobile phase is finding increasing numbers of applications in a wide variety of industries for the extraction, separation, and cleaning of materials. This study assessed the usefulness of this approach in removing surface contaminants from a knitted polyester anterior cruciate ligament (ACL) prosthesis before packaging and sterilizing the product during manufacture. The physical, dimensional, and chemical properties of SFE treated compared with commercially scoured control samples were characterized using a number of textile test methods: electron spectroscopy for chemical analysis, Fourier transform infrared spectroscopy, differential scanning calorimetry, and solvent extraction analysis. The biocompatibility of the samples was measured in terms of their ability to generate CD18 integrin expression on activated human polymorphonuclear cells, and their inflammatory response when implanted for up to 30 days in the knee joint of rats. SFE treatment was successful in removing most of the nonpolar contaminants from the ACL prosthesis and reducing the amount of residuals to a commercially acceptable level. However, some nitrogen containing compounds and polar salts were not removed by the SFE process. The results from the biocompatibility tests demonstrated that the cleaner SFE treated prosthesis induced significantly lower CD18 expression than the scoured control fabric, and was also associated with a milder inflammatory response and a more rapid rate of healing during the 30 day animal trial. Another effect of SFE processing was to cause the polyester device to shrink and lose porosity because of yarn contraction and modification of the polymer's microcrystalline structure.

Assessment of deep vein thrombosis prophylaxis in surgical patients: a study conducted at Nancy University Hospital, France.

OBJECTIVE: This retrospective evaluation aimed to assess the adequacy of prophylaxis against thromboembolism prescribed to surgical patients at the authors' institution, and to compare it with generally accepted published guidelines. Aspects considered were indications for prophylaxis, regimens used and monitoring. METHODS: Eleven units (nine surgical and two surgical intensive care) took part in the survey on a voluntary basis. The clinical audit system used involved developing a set of criteria based on existing guidelines, comparing observed practice with those recommendations, analysing the factors underlying any deviation and developing corrective measures. RESULTS: When the medical records of 117 patients hospitalized in October 1995 were examined, prophylaxis against deep vein thrombosis was documented in 86 (low molecular weight heparin in 85, dextran in one). No associated physical preventative measures were recorded. Indications and dosage were appropriately handled in 90.7% and 75.2% of patients, respectively. Ninety-five cases were outside the reference criteria: 74 for excluded surgical indications, 13 which involved laparoscopy, and eight in which spinal or epidural anaesthesia was administered. Platelet count was performed in 73.8% of cases before prophylactic treatment, and in 23.10% during its course. Anti-Xa activity was measured in 0.4% of cases. Analysis of causes showed that guidelines were not complied with either because of lack of organization, or because of disagreement with them. DISCUSSION: In this study, indications for prophylaxis were well established and heparin dosages used were not fundamentally flawed. The weak point in practice was a failure to carry out platelet counts, particularly during the course of treatment. Appropriate corrective action consists of disseminating guidelines and relevant information, and using a preoperative checklist to assess thromboembolic risk. CONCLUSION: Physicians agree that opportunities to improve preventative practices exist, and that the quality improvement programme should be pursued.

[Flatfoot]. / Pied plat.

The flat foot is a very frequent cause of consultation in podology. The lesion is rapidly fixed, and osteoarthrosis appears. The diagnosis is clinical. A podoscopic and radiographic examination is necessary to appreciate the evolutivity of the deformity. The treatment is almost conservative: the wearing of orthesis is often sufficient. The indications of the surgery are rare; sometimes it is possible to do plastic techniques (in particular on the posterior tibial tendon) but, when the foot is painful, the osteoarthrosis is present and it is necessary to do arthrodesis, in particular in the talonavicular joint.

[Current treatment of static deformities of the great toe]. / Traitement actuel des déformations statiques du gros orteil.

The modern techniques of treatment of the hallux valgus are founded on the biomechanic and permit to give again a good function of the big toe. The authors prefer the osseous methods and specially the phalangeal and metatarsal osteotomies. It is necessary also to do a lateral release of the metatarsophalangeal joint and an exostosectomy. The late results are good.

Evaluation of the effect of three surface treatments on the biocompatibility of 316L stainless steel using human differentiated cells.

AISI 316L stainless steel (SS) is widely used in orthopaedic implantology, although biological complications may result from its insufficient mechanical and tribological properties. In order to improve the wear and corrosion resistance as well as the hardness of 316L SS, three surface treatments, derived from those applied in mechanical engineering industries, were investigated: (1) glow discharge nitrogen implantation, (2) carbon-doped stainless steel coating sputtering and (3) low temperature plasma nitriding. Surface characterization according to the different heat treatments showed that corrosion and wear resistance were strongly improved, especially by ion implantation or carbon-doped SS coating sputtering. In the same way, microhardness was significantly increased after the three treatments. The effect of such treatments on the biocompatibility of 316L SS was studied with human osteoblast and fibroblast cultures. Basic and specific features of the cells showed that ion-implanted and carbon-doped stainless steels were biocompatible, whereas dramatic cellular reactions were noted when contacted with nitrided stainless steel. A hypothesis is given to explain this observation but further experiments are needed to optimize the nitriding process. Nitrogen implantation and carbon-doped layer deposition could be efficient means for improving the physical properties of stainless steel without affecting its biocompatibility. Such surface treatments may have relevance for increasing the life time of 316L biomedical devices.

[The Staca nail-plate in the treatment of trochanteric fractures]. / Le clou-plaque Staca dans les fractures trochantériennes.

PURPOSE OF THE STUDY: The Staca nail-plate (SNP) is 32 years old. This implant was created by Descamp and Kerner from Nice in 1964. This study evaluates the experience with the SNP in two Orthopaedic Departments from Metz and Nancy Regional Hospitals, between January 1989 and July 1991. MATERIAL AND METHODS: This is a clinical and radiological retrospective study. Out of the 175 patients, 152 were reviewed at 3 months and 127 at more than 9 months. The radiological assessment was made by measuring the post-operative cervical angle, the position of the nail within the femoral neck, the inter-fragmentary distance and the distance between nail and femoral head cartilage. 175 trochanteric fractures (119 women and 56 men) had osteosynthesis with the SNP. The mean age was 79 years (range: 36 to 96 years). Only 29 patients were free of general associated pathology. The fracture was always traumatic. The right femur was involved in 97 cases. Following the Ender classification there were 87 stable and 88 unstable fractures (59 complex pertrochanteric, 19 inter and sub-trochanteric and trochantero-diaphyseal). RESULTS: Post-operative reduction was anatomical in 66 per cent and satisfactory in 89 per cent of cases. In three cases there was an acetabular protrusion of the nail, in two cases there was a varus reduction and fixation and in six cases the plate was not fitting correctly the diaphysis. The average per-operative blood-loss was 300 cc. There was one per-operative death and eight early post-operative deaths. Sitting was allowed 24 hrs, after surgery in 94 per cent of patients. 68 per cent of patients started walking within the first 15 days after surgery. There were 37 per cent general complications, mainly respiratory and urinary infections, but also 2 deep-vein phlebitis, with pulmonary embolism and death. 17 post-operative hematoma were noted, out of which two required surgery. The general mortality reached 15 per cent in three months and 22 per cent in nine months. 70 per cent of the patients were free of pain at 3 months and 78 per cent at 9 months, 65 per cent being able to walk without crutches. Nail acetabular protrusion was observed in 16 cases (3 in early post-operative period, 8 within three months and 2 between the third and the ninth month). The protrusion was related to the nail positioning in 11 out of the 16 cases. This complication required SNP removal in 7 cases, replacement of the SNP in 3 cases and total hip arthroplasty in two cases. Correct nail length assessment is the important step in order to avoid protrusion and has to take into account the interfragmentary distance after reduction (if any). A good per-operative nail impaction is mandatory. CONCLUSION: Compared to other implants (THS, DHS, Gamma-nail, Ender), the SNP gives comparable results and a stable fixation. The SNP is a reliable implant. The most common complication in our series is protrusion which required reintervention in 6.8 per cent of the cases. Currently we avoid this complication by a good per-operative nail impaction.

[Open fractures of the leg - Series from the University Hospital of Nancy]. / Fractures ouvertes de jambe - La série de C.H.U. de Nancy.

Thirteen cases from two teams were studied retrospectively between 1983 and 1992. There were 11 men and 2 women with an average of 30 years (16-52 years). Nine were due to road traffic accidents and in 3 cases the fracture involved the upper third, 5 cases the middle third and 5 cases the lower third of the tibia. Six patients suffered from multiple injuries. Arteriography was used in 6 cases. Initial debridement was adequate in 9 cases but required to be redone in 3. In one case it required to be repeated several times. Antibiotics were given for an average of 28 days but if 2 infected cases are withdrawn antibiotics were only given for 11 days. Fixation was by external fixator in all cases except for one which was placed on traction. In 4 cases the external fixator required to be changed secondarily. Skin cover was obtained by 6 latissimus dorsi free flaps, one free inguinal flap and 2 local flaps of tibius anterior and medial gastrocnemius. Four free posterior iliac crest transplants and one free fibula were done between the 12th day and 2nd month after injury. Additional bone was added in 3 cases by a conventional cortico-cancellus graft done secondarily. Each patient had an average of 6 operations (3-17). The length of hospitalisation was an average of 3 months (1-6 months).Consolidation took on average 12 months (6-27). There were no necroses of skin flaps. Five non-unions were treated by a secondary bone graft and changing the fixator. One infected non-union was treated successfully by the Ilizarov method. One amputation because of osteomyelitis resulted from the latissimus dorsi flap which was done too late. There were 4 cases of pes cavus with toe clawing and one ankle joint became completely stiff.The overall results are comparable to those of the S.O.T.EST Round Table. Return to work was on average 20 months (9-42) either with or without change in occupation.This series is characterised by the systematic use of an external fixator and by the number of latissimus dorsi free flaps (6) to obtain cover and liberal use of bone grafts to ensure consolidation. The authors emphasise that early flap cover before the 21st day saves time by avoiding trophic changes and led to consolidation in an average of 9 months compared to 12 months for the overall series.

Prognostic factors for quality of life after trochanteric fracture : Inter-regional study S.O.T.EST.

The aim of the study was to determine factors influencing functional ability and quality of life 6 months after surgically treated trochanteric fractures.A multicenter cohort included 459 patients (365 females, 103 males, mean age 80.5 years) in Eastern France. They presented with stable (62%) and unstable (38%) fractures. Six months after surgery, functional ability and quality of life were assessed by Merle d'Aubigné, Harris and Duke Health profile scores, or return to home.In logistic regression analysis, age was the most prominent factor predicting low functional ability and quality of life. The implant material similarly predicted poor functional ability and level of quality of life, probably through the different strategies for care management they involved. The quality of fracture reduction assessed on lateral radiograph as well as post-operative complications were predictors of a better functional ability. A delayed weight bearing was also suggested to predict better quality of life in these patients.