Antibiotic prophylaxis in primary hip and knee arthroplasty: comparison between cefuroxime and two specific antistaphylococcal agents.

This is a prospective randomized study comparing cefuroxime to 2 antistaphylococal agents (fusidic acid and vancomycin), for prophylaxis in total hip arthroplasty (THA) and total knee arthroplasty (TKA) in an institute, where methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus epidermidis (MRSE) prevalence exceeds 25% of orthopedic infections. There were 3 patient groups. Group A included the patients who received cefuroxime, group B those who received fusidic acid, and group C those who received vancomycin. Patients were evaluated for the presence of superficial and/or deep infection at the surgical site. Statistical analysis did not reveal any substantial difference between the 3 groups. We do not recommend the use of specific antistaphylococcal agents for prophylactic use in primary THA and TKA, even in institution where MRSA and MRSE exceed 25% of orthopedic infections.

Dosimetry during intramedullary nailing of the tibia.

BACKGROUND: Intramedullary nailing under fluoroscopic guidance is a common operation. We studied the intraoperative radiation dose received by both the patient and the personnel. PATIENTS AND METHODS: 25 intramedullary nailing procedures of the tibia were studied. All patients suffered from tibial fractures and were treated using the Grosse-Kempf intramedullary nail, with free-hand technique for fixation of the distal screws, under fluoroscopic guidance. The exposure, at selected positions, was recorded using an ion chamber, while the dose area product (DAP) was measured with a DAP meter, attached to the tube head. Thermoluminescent dosimeters (TLDs) were used to derive the occupational dose to the personnel, and also to monitor the surface dose on the gonads of some of the patients. RESULTS: The mean operation time was 101 (48-240) min, with a mean fluoroscopic time of 72 seconds and a mean DAP value of 75 cGy x cm(2). The surface dose to the gonads of the patients was less than 8.8 mGy during any procedure, and thus cannot be considered to be a contraindication for the use of this technique. Occupational dose differed substantially between members of the operating personnel, the maximum dose recorded being to the operator of the fluoroscopic equipment (0.11 mSv). INTERPRETATION: Our findings underscore the care required by the primary operator not to exceed the dose constraint of 10 mSv per year. The rest of the operating personnel, although they do not receive very high doses, should focus on the dose optimization of the technique.

Intramedullary nailing for the treatment of aseptic femoral shaft non-unions after plating failure: effectiveness and timing.

This retrospective, multicentre study aimed to evaluate reamed intramedullary nailing (IMN) for the treatment of 30 cases of aseptic femoral shaft non-union after plating failure. Following nailing, 29 non-unions had healed by a mean 7.93 months. In one case a hypertrophic non-union required renailing after 8 months, using a nail of greater diameter, and united within five further months. Healing times were not related to whether the fracture was open or closed, the type non-union or the type of fracture. The delay from the initial plating to intramedullary nailing had a statistically significant effect on healing time and final outcome. This treatment is cost effective and should be implemented as soon as the non-union is diagnosed.

Treatment of unstable lower cervical spine injuries by anterior instrumented fusion alone.

STUDY DESIGN: Retrospective study of a prospectively followed cohort. OBJECTIVE: To summarize the complications after instrumented stabilization of cervical spine injuries in a single-institution series, and to discuss management of unstable injuries with respect to the complication rate between the 2 approaches (anterior and posterior). SUMMARY OF BACKGROUND DATA: The anterior approach to the cervical spine has been criticized for destruction of the anterior elements in the presence of posterior instability. The data came mainly from biomechanical studies and older clinical studies with earlier implants. However, there has been growing evidence ever since, that anterior decompression and instrumented fusion alone is an adequate form of treatment for unstable cervical spine injuries. METHODS: Over a 16-year period (1989 to 2005), 112 patients were treated in our institution for unstable cervical spine injuries using either anterior, posterior stabilization, or both. A patient was considered to have an unstable injury if he had 5 points or more in the White and Panjabi instability checklist. At least 1-year follow-up was necessary for a patient to be included in the study, which yielded a total of 97 patients. Seventy-four patients underwent anterior stabilization (group A) and 23 patients underwent posterior stabilization (group B). Three patients in the posterior surgery group required supplemental anterior cervical stabilization. RESULTS: Clinically significant complications occurred in 9/74 (12.2%) patients of group A. Three of 74 patients (4%) were reoperated owing to significant screw backout causing dysphagia, no purchase of the screws being completely in the adjacent disc and screw breakage, respectively. In group B, clinically significant complications were recorded in 4 (17.4%) patients, with an overall reoperation rate of 4% (1/23). Statistical analysis did not reveal significant differences between the 2 groups. CONCLUSIONS: Anterior instrumented fusion is at least as efficient as the posterior procedure in the management of cervical spine injuries and it also has several advantages. Most of such injuries, including the dislocations, can be managed with anterior instrumented fusion alone. Simple means of immobilization such as the hard collar suffice, and secondary posterior fixation is rarely, if ever, necessary.

The adult spinal cord injury without radiographic abnormalities syndrome: magnetic resonance imaging and clinical findings in adults with spinal cord injuries having normal radiographs and computed tomography studies.

BACKGROUND: Spinal cord injury without radiographic abnormalities (SCIWORA) is thought to represent mostly a pediatric entity and its incidence in adults is rather underreported. Some authors have also proposed the term spinal cord injury without radiologic evidence of trauma, as more precisely describing the condition of adult SCIWORA in the setting of cervical spondylosis. The purpose of the present study was to evaluate adult patients with cervical spine injuries and radiological-clinical examination discrepancy, and to discuss their characteristics and current management. METHODS: During a 16-year period, 166 patients with a cervical spine injury were admitted in our institution (Level I trauma center). Upper cervical spine injuries (occiput to C2, 54 patients) were treated mainly by a Halo vest, whereas lower cervical spine injuries (C3-T1, 112 patients) were treated surgically either with an anterior, or posterior procedure, or both. RESULTS: Seven of these 166 patients (4.2%) had a radiologic-clinical mismatch, i.e., they presented with frank spinal cord injury with no signs of trauma, and were included in the study. Magnetic resonance imaging was available for 6 of 7 patients, showing intramedullary signal changes in 5 of 6 patients with varying degrees of compression from the disc and/or the ligamentum flavum, whereas the remaining patient had only traumatic herniation of the intervertebral disc and ligamentum flavum bulging. Follow-up period was 6.4 years on average (1-10 years). CONCLUSION: This retrospective chart review provides information on adult patients with cervical spinal cord injuries whose radiographs and computed tomography studies were normal. It furthers reinforces the pathologic background of SCIWORA in an adult population, when evaluated by magnetic resonance imaging. Particularly for patients with cervical spondylosis, special attention should be paid with regard to vascular compromise by predisposing factors such as smoking or vascular disease, since they probably contribute in the development of SCIWORA.

Long-term results in surgically treated acetabular fractures through the posterior approaches.

BACKGROUND: The long-term results of surgically treated displaced acetabular fractures using the posterior approaches and the possible role of the greater trochanteric osteotomy in the development of heterotopic ossification (HO) are still somehow controversial despite extensive publications. METHODS: Seventy-five patients with an acetabular fracture and displacement of at least 3 mm were surgically treated during a 6-year period. The duration of the follow-up was from 10 to 15 years, with a mean of 12.5 years. RESULTS: The over-all satisfactory clinical result, grouping together the excellent and good results, was 80%. There was a good correlation between clinical and radiologic results. The most common complication was HO, observed in 19 patients (25.3%). The extended iliofemoral approach had the greater incidence of HO (40%), whereas the least was observed in the Kocher-Langenbeck approach with osteotomy of the greater trochanter (21.4%). Moreover, posttraumatic osteoarthrosis was observed in eight patients (10.7%) and osteonecrosis of the femoral head in six (8%). CONCLUSIONS: Surgical treatment of the acetabular fractures aiming at anatomic reduction of the acetabulum and congruency with the femoral head is the prerequisite for a favorable functional outcome in the long term. In most cases, the Kocher-Langenbeck approach is adequate. Trochanteric osteotomy is indicated only for fractures extending toward the anrerior column and this facilitates exposure, anatomic reduction, and fixation. No statistically significant difference was found between the surgical approach and heterotopic bone formation.

Anterior traumatic shoulder dislocation associated with displaced greater tuberosity fracture: the necessity of operative treatment.

OBJECTIVE: To evaluate the radiographic and clinical outcome, including the incidence of recurrence, in patients with displaced greater tuberosity (GT) fractures associated with a traumatic anterior shoulder dislocation. DESIGN: Retrospective study. SETTING: University Hospital (Level 1 trauma center). PATIENTS: There were 34 completely evaluated patients (19 male, 15 female) seen between 1993 and 2002 with a displaced GT fracture associated with a traumatic anterior shoulder dislocation. Average age was 52.8 years and the mean follow-up period was 4.8 years (range, 2.0 to 10 years). INTERVENTION: All GT fractures were internally fixed solely with heavy non-absorbable sutures and any associate rotator cuff tear was repaired at the same time. A special rehabilitation protocol was administered in all patients. MAIN OUTCOME MEASUREMENTS: Functional assessment was obtained using the parameters of the Constant score which grades outcomes as excellent, very good, good and poor. RESULTS: Overall, there were 25 (73.5%) excellent, 6 (17.6%) very good, 2 (5.8%) good and 1 (3.1%) poor results, and the average Constant score was 88.4 (range 45.0 to 100.0). All fractures healed radiographically, without evidence of secondary displacement, except in one patient. No case of recurrence of dislocation was noted in any patient. Partial absorption or "lysis" of the GT without significant clinical relevance was detected in 4 cases. CONCLUSIONS: Displaced fractures of the GT after traumatic anterior shoulder dislocation may result in limitation of motion and functional disability if they are not treated promptly by surgery. Open reduction and stable fixation of the GT along with rotator cuff repair when present, allows for early passive motion of the joint, and yields excellent final results in approximately three quarters of the patients and restores their ability to return to full activities of daily living. A compliant patient is also necessary for a successful result.

Current Concepts: Aseptic Nonunion of Femoral Shaft Diaphysis.

In spite of increased understanding of biomechanics and improvements of implant design, nonunion of femoral shaft fractures continues to hinder the treatment of these injuries. Femoral nonunion presents a difficult treatment challenge for the surgeon and a formidable personal and economic hardship for the patient. In most series of femoral fractures treated with intramedullary nailing techniques, the incidence of this complication is estimated to be 1%. A higher frequency has recently been reported due to advances in trauma care leading to increased survivorship among severely injured patients and expanded indications of intramedullary nailing. Whereas the treatment of femoral shaft fractures has been extensively described in the orthopedic literature, the data regarding treatment of femoral shaft nonunions are sparse and conflicting, as most of the reported series consisted of a small number of cases. However, careful review of the existing literature does provide some answers regarding either conservative or operative management. The gold standard for femoral shaft nonunions invariably includes surgical intervention in the form of closed reamed intramedullary nailing or exchange nailing, but several alternative methods have been reported including electromagnetic fields, low-intensity ultrasound, extracorporeal shock wave therapy, external fixators and exchange or indirect plate osteosynthesis. In this paper, a comprehensive review of the current treatment modalities for aseptic midshaft femoral nonunion is presented, after a concise overview of the incidence, definition, classification and risk factors of this complication.

Functional outcome of surgical treatment for multilevel lumbar spinal stenosis.

BACKGROUND: There is no consensus regarding the best treatment of patients with multilevel lumbar stenosis. We evaluated the clinical and radiological findings in 41 patients with complex degenerative spinal stenosis of the lumbar spine who were treated surgically. METHODS: Between 1997 and 2003, 41 patients suffering from degenerative lumbar spinal stenosis were included in a prospective clinical study. The spinal stenosis was multilevel in all patients and in 13 of them there was degenerative scoliosis, in 18 there was degenerative spondylolisthesis, and in 10 there was segmental instability. Plain radiographs, MRI and/or CT myelograms were obtained preoperatively. The patients were assessed clinically with the Oswestry disability index (ODI) and visual analog scale (VAS). Surgery included wide posterior decompression and fusion using a trans-pedicular instrumentation system and bone graft. RESULTS: After a mean follow-up of 3.7 (1-6) years, the patients' clinical improvement on the ODI and VAS was statistically significant. Recurrent stenosis was not observed, and 39 of 41 patients were satisfied with the outcome. 3 patients with improvement initially had later surgery because of instability. INTERPRETATION: The above-mentioned technique gives good and long lasting clinical results, when selection of patients is done carefully and when the spinal levels that are to be decompressed are selected accurately.

Graft-supplemented, augmented external fixation in the treatment of intra-articular distal radial fractures.

This article compares the functional and radiographic outcomes of intraarticular distal radial fractures treated with augmented external fixation in which autologous cancellous bone grafting or Norian SRS (Norian Corp, Cupertino, Calif) was used for filling the metaphyseal void. Thirty non-randomized patients, 15 in each group, with AO type C distal radius fractures (20 men and 10 women; average age: 48 years) were operatively treated between 1998-2000 and retrospectively evaluated. Radial inclination, radial length, volar tilt, and Modified Mayo Wrist Score were assessed at the most recent follow-up evaluation (average: 33.3 months). Overall, 12 (80%) patients in the Norian group had an excellent or good result, 2 had fair, and 1 had poor. In the autologous iliac bone graft group, the results were excellent or good in 11 (73.3%) patients, fair in 1, and poor in 2. No statistical difference between the two types of grafting was noted. Norian SRS is equally effective to cancellous bone as supplementary graft in comminuted distal radial fractures treated by external and Kirschner-wire fixation.

Double-loop suture repair for acute acromioclavicular joint disruption.

BACKGROUND: Although it has been established that surgical treatment for acromioclavicular joint disruption (types IV-VI and type III in overhead throwing athletes and heavy laborers) is preferred, the literature is inconclusive about the best type of surgery. PURPOSE: With the goal of avoiding the potential complications of hardware use, the authors present a coracoclavicular functional stabilization technique with the intention to restore the anteroposterior and superior displacement of the clavicle. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From 1999 to 2003, 38 patients with an acute, complete acromioclavicular joint separation (34 men, 4 women; mean age, 33.5 years) underwent surgical reconstruction with the described coracoclavicular loop stabilization technique. With this technique, the superior and anteroposterior displacement of the clavicle can be easily controlled using 2 pairs of Ethibond No. 5 nonabsorbable sutures-one passed in front and the other behind the clavicle, through a central drill hole, 2 cm from its lateral end, directly above the base of the coracoid process (at the corresponded attachment of coracoclavicular ligaments). Passive shoulder motion was encouraged by the second postoperative day. RESULTS: Thirty-four patients were available for the last clinical and radiologic evaluation. At a mean follow-up of 33.2 months (range, 18-59 months), the mean Constant-Murley score was 93.5 points (range, 73-100 points), and 2 cases with slight loss of reduction (less than half of the width of the clavicle) were detected. Complications included 1 case with superficial infection and 1 patient (basketball player) with persistent tenderness in the acromioclavicular joint without signs of secondary arthritis. The incidence of periarticular ossification was 17.6% and did not affect the final outcome. Secondary degenerative changes were not detected. CONCLUSION: Considering the nearly anatomical reconstruction, the avoidance of hardware complications, and the low rate of recurrence, this technique may be an attractive alternative to the management of acute acromioclavicular joint separations.

Herbert screw fixation and reverse guided drillings, for treatment of types III and IV osteochondritis dissecans.

We evaluated the outcome in 10 young patients, ages ranging from 15 to 26, with types III and IV osteochondritis dissecans of the knee, treated with Herbert screws fixation and reverse guided drillings. The disease involved the medial femoral condyle in eight patients and the lateral in two. Diagnosis and preoperative planning based on plain radiographs (AP, lateral and tunnel view) and MRI (in seven patients). Fixation of the fragment with Herbert screws using a mini-arthrotomy technique and additional reverse drillings behind the crater of the lesion using the ACL aiming devise were performed in all patients. Post-operatively, no weight bearing was recommended for at least three months. The follow-up ranged from 15 months to 38 months (mean 27 months). According to the subjective questionnaire of the International Cartilage Repair Society (ICRS) scale, seven patients had normal knees, two had nearly normal knees and one abnormal. The Lysholm Knee score ranged 65-96 points (mean 88 points). All patients except one returned to their previous activities and they were satisfied with the result. Radiological union of the fragment was found in 9/10 patients (six grade III, three grade IV). Progressive flattening of the injured femoral condyle was noticed in two patients (grade III). Securing the lesion using Herbert screws in combination with reverse guided drillings seems to be an effective treatment choice for detached or displaced osteochondral fragments.

Sexual function in females with severe cervical spinal cord injuries: a controlled study with the Female Sexual Function Index.

The objective of this study was to identify the sexual adjustment of females with severe cervical spinal cord injuries (SCI) using the Female Sexual Function Index (FSFI). The 19-item questionnaire of the FSFI concerns sexual function and satisfaction in sex life. This study, conducted by the Orthopaedic and Psychiatry Departments of Patras University, used a sample of a series of 39 consecutive female patients with severe traumatic SCI. We compared these female patients with an age-economic-educational level- and marital status-matched control group of the general population. Sexual activity was lower among females with SCI, but the desire, the emotional quality of sex life and overall sexual satisfaction did not differ from the controls. These results demonstrate that sexual life in females with SCI remains almost unaffected.

Alteration in serum leptin correlates with alterations in serum N-telopeptide of collagen type I and serum osteocalcin during the progression of osteoporosis in ovariectomized rats.

The role of leptin during the progression of osteoporosis was investigated in ovariectomized rats by correlation of serum leptin levels with N-telopeptide of collagen type I (NTx) and osteocalcin levels before ovariectomy and 20, 40 and 60 days after the operation. Furthermore, peripheral quantitative computed tomography was used to confirm the development of severe osteoporosis in rats on day 60. The levels of NTx and osteocalcin were significantly increased on day 20 [61.9+/-5.4 nM BCE (bone collagen equivalents) and 215.6+/-53.3 ng/mL, respectively] in comparison to those before ovariectomy (41.3+/-1.7 nM BCE and 60.4+/-10.9 ng/mL). Accordingly, leptin was significantly elevated on day 20 (3033+/-661 vs. 606+/-346 pg/mL before ovariectomy). Bone markers and leptin levels remained constant up to day 40, while a slight, but not statistically significant, decrease was noted for osteocalcin and leptin on day 60. Although leptin and bone markers did not correlate before ovariectomy (r=0.09 for NTx and r=-0.05 for osteocalcin), strong correlation was observed at all time points after ovariectomy. The data obtained suggest that the alterations in serum leptin levels during the progression of osteoporosis in ovariectomized rats follow the alterations in bone markers.

Minimal internal fixation augmented by small wire transfixion frames for high-energy tibial plateau fractures.

PURPOSE: To evaluate the outcome of bicondylar tibial plateau fractures treated with minimal internal fixation augmented by small wire external fixation frames and to assess the necessity of bridging the knee joint by extending the external fixation to the distal femur. METHODS: This is a retrospective study of 48 tibial plateau fractures. There were 40 (83.5%) Schatzker type VI fractures, 8 Schatzker type V fractures, and 18 (37.5%) fractures were open. A complex injury according to the Tscherne-Lobenhoffer classification was recorded in 30 (62.5%) patients. All fractures were treated with combined minimally invasive internal and external fixation. Closed reduction was achieved in 32 (66.6%) of the fractures. Extension of the external fixation to the distal femur was done in 30 (62.5%) fractures. Results were assessed according to the criteria of Honkonen-Jarvinen. RESULTS: Follow-up ranged from 28 to 60 months with an average of 38 months. All fractures but 1 united at an average of 13.5 weeks (range 11-18 weeks). One patient developed an infected nonunion of the diaphyseal segment of his fracture. Thirty-nine (81%) patients achieved an excellent or good radiologic result. An excellent or good final clinical result was recorded in 36 patients (76%). Bridging the knee joint did not affect significantly the result (P < 0.418). No significant correlation was found between the type of fracture and the final score (P < 0.458). CONCLUSIONS: Hybrid internal and external fixation combined with tibiofemoral extension of the fixation is an attractive treatment option for complex tibial plateau fractures.

Correlative radiological, self-assessment and clinical analysis of evolution in instrumented dorsal and lateral fusion for degenerative lumbar spine disease. Autograft versus coralline hydroxyapatite.

This prospective longitudinal randomized clinical and radiological study compared the evolution of instrumented posterolateral lumbar and lumbosacral fusion using either coralline hydroxyapatite (CH), or iliac bone graft (IBG) or both in three comparable groups, A, B and C, which included 19, 18 and 20 patients, respectively, who suffered from symptomatic degenerative lumbar spinal stenosis and underwent decompression and fusion. The patients were divided randomly according to the graft used and the side that it was applied. The spines of group A received autologous IBG bilaterally; group B, IBG on the left side and hydroxyapatite mixed with local bone and bone marrow on the right side; group C, hydroxyapatite mixed with local bone and bone marrow bilaterally. The age of the patients in the groups A, B and C was 61+/-11 years, 64+/-8 years and 58+/-8 years, respectively. The SF-36, Oswestry Disability Index (ODI), and Roland-Morris (R-M) surveys were used for subjective evaluation of the result of the surgery and the Visual Analogue Scale (VAS) for pain severity. Plain roentgenograms including anteroposterior, lateral and oblique views, and lateral plus frontal bending views of the instrumented spine and CT scan were used to evaluate the evolution of the posterolateral fusion in all groups and sides. Two independent senior orthopaedic radiologists were asked to evaluate first the evolution of the dorsolateral bony fusion 3-48 months postoperatively with the Christiansen's radiologic method, and secondly the hydroxyapatite resorption course in the spines of groups B and C. The diagnosis of solid spinal fusion was definitively confirmed with the addition of the bending views, CT scans and self-assessment scores. The intraobserver and interobserver agreement (r) for radiological fusion was 0.71 and 0.69, respectively, and 0.83 and 0.76 for evaluation of CH resorption. T(12)-S(1) lordosis and segmental angulation did not change postoperatively. There was no radiological evidence for non-union on the plain roentgenograms and CT scans. Radiological fusion was achieved 1 year postoperatively and was observed in all groups and vertebral segments. Six months postoperatively there was an obvious resorption of hydroxyapatite granules at the intertransverse intersegmental spaces in the right side of the spines of group B and both sides of group C. The resorption of hydroxyapatite was completed 1 year postoperatively. Bone bridging started in the third month postoperatively in all instrumented spines and all levels posteriorly as well as between the transverse processes in the spines of the group A and on the left side of the spines of group B where IBG was applied. SF-36, ODI, and R-M score improved postoperatively in a similar way in all groups. There was one pedicle screw breakage at the lowermost instrumented level in group A and two in group C without radiologically visible pseudarthrosis, which were considered as having non-union. Operative time and blood loss were less in the patients of group C, while donor site complaints were observed in the patients of the groups A and B only. This study showed that autologous IBG remains the "gold standard" for achieving solid posterior instrumented lumbar fusion, to which each new graft should be compared. The incorporation of coralline hydroxyapatite mixed with local bone and bone marrow needs adequate bleeding bone surface. Subsequently, hydroxyapatite was proven in this series to not be appropriate for intertransverse posterolateral fusion, because the host bone in this area is little. However, the use of hydroxyapatite over the decorticated laminae that represents a wide host area was followed by solid dorsal fusion within the expected time.

Midterm results of treatment with a retrograde nail for supracondylar periprosthetic fractures of the femur following total knee arthroplasty.

OBJECTIVES: Although the short-term results of supracondylar periprosthetic fractures treated with retrograde nailing have been satisfactory, there is always a concern about the long-term survival of the prosthesis. The aim of the study was to evaluate fracture healing and knee functional outcome with a follow-up time of at least 2 years in periprosthetic fractures of the knee treated with a supracondylar nail. DESIGN: Cohort study. PATIENTS: There were 9 patients with 10 periprosthetic fractures. In 1 patient, the fracture occurred intraoperatively. In the others, the time between the total knee arthroplasty and the periprosthetic fracture ranged between 2 weeks and 7 years (average time: 2.78 years). The mean follow-up was 34.5 months (25-52 months). MAIN OUTCOME MEASUREMENTS: The Western Ontario and McMaster Universities index was used to evaluate the functional result postoperatively using the paired t test as the statistical test. Fracture union was assessed with plain x-rays. RESULTS: All the fractures united within 3 months. One fracture united in extreme valgus (35 degrees) and was revised to a stemmed total knee replacement. There were no infections and no prosthesis loosening. The paired t test before the fracture and after the operation demonstrated no statistically significant differences; however, there was a trend toward lower functional score postoperatively. CONCLUSIONS: It appears that retrograde nailing is a reliable technique to treat periprosthetic supracondylar fractures. It provides adequate stability until fracture union. The morbidity of the operation is minimal, and the complication rate is low. The midterm results in our study showed that none of the prostheses required revision. In our opinion, it is the treatment of choice for a periprosthetic fracture when the prosthesis is stable.

Modified extra rotator-cuff entry point in antegrade humeral nailing.

INTRODUCTION: We describe an extra-articular, extra-rotator cuff entry point for antegrade humeral nailing, which preserves the articular surface and rotator cuff integrity. MATERIAL AND METHODS: Thirty-two patients with humeral shaft fractures underwent antegrade intramedullary nailing using a modified insertion point located 1 cm below the crest of the greater tuberosity, in a region outside the articular surface and rotator cuff area. RESULTS: In all cases, nailing was done successfully, without any perforation of the humeral inner cortex by the nail. Extension of the fracture line to the distal metaphysis happened intraoperatively in one case of a distal diaphysis fracture. In the remainder of the patients, postoperative reduction of the fracture was successful, with no sign of an iatrogenic incident of fracture comminution. Excellent active shoulder function and full early functional recovery of the shoulder joint (to 16th week postoperatively) were established in 98% of the patients. All fractures were united in a mean period of 14 weeks. CONCLUSION: We suggest an extra-articular, extra-rotator cuff entry point for antegrade humeral nailing as a possible and safe technique with beneficial results for the shoulder's postoperative function.