Distal locking of femoral nails. Mathematical analysis of the appropriate targeting range.

BACKGROUND: During the last decades, intramedullary nailing has become the standard treatment for diaphyseal fractures of long bones. Numerous innovative techniques and devices have been proposed to simplify distal locking. Each has its own limitations and, as a result, the fluoroscopy-dependent "free-hand technique" remains the most popular method. However, radiation exposure to the patient and operating room staff remains a concern. METHODS: Before the development of a new radiation-independent, nail-mounted targeting system, we mathematically analyzed the aiming accuracy that such a system has to achieve. The correctness of this mathematical model was evaluated using a mechanical testing apparatus. FINDINGS: We found a quite large targeting range for the unimpeded passage of the drill bit through the locking hole of a given nail. Important degrees of nail bending can thereby be compensated. As predicted by the mathematical formula, a 4-mm drill bit passed the distal locking hole of a 320/11mm femoral nail up to a deflection of ±13mm in the coronal plane. INTERPRETATION: This mathematical model can be considered to be an additional tool for the development of new targeting devices. Combining our mathematical model with data previously published, not only torsional deformation along the longitudinal axis of the nail but also bending in the coronal plane can approximately be neglected. Hence, the three-dimensional aiming process can be simplified to the determination of the interlocking hole of the nail in the sagittal plane provided that the insertion-induced nail deformation in vivo stays in the range of that observed in vitro. LEVEL OF EVIDENCE: Level III. Basic sciences control study.

Periprosthetic femoral fractures treated by locked plating: feasibility assessment of the mini-invasive surgical option. A prospective series of 36 fractures.

INTRODUCTION: The treatment of periprosthetic femoral fractures by conventional plating is associated with problems related to fracture union and eventual refracture. Additionally, locking nailing cannot be used in all cases because of the risk of malunion. To resolve these issues, locking plates have been proposed to combine the advantages of closed reduction and internal fixation while achieving a higher quality reduction with plate fixation. HYPOTHESIS: Locking plates put into place by a mini-invasive surgical approach result in fixation without substantial misalignment or non-union. PATIENTS AND METHODS: From June 2002 to December 2007 we prospectively treated 35 patients (one bilateral), 28 women and seven men with a fracture around the hip implant (21), around the knee (8), between the hip implant and the knee (2), between a trochanteric internal fixation device and the knee implant (5). The mean age was 76, (39-93). Internal fixation was always attempted by mini-invasive surgery using locking plate system with locking screws (Synthès™). Rehabilitation included immediate weight bearing with as much weight as the patient would tolerate. The preoperative Parker score was 5.25 (0-9). RESULTS: There was one patient lost to follow-up, one early failure, and seven deaths (four of whom were included in the study group since their follow-up was at least 24 months) for a total of 31 fractures (30 patients), the mean follow-up for the series was 26 months (6-67). Twenty-six fixations were performed by mini-invasive approach and 10 through a conventional open surgery. Patients applied full weight (n=20), partial weight (n=3) or no weight for 6 weeks (n=13). Infections developed in two patients and there were three cases of mechanical failure. Fracture union was achieved in 35 out of 36 cases. More than 5° of misalignment was observed in five patients. Loosening of the implant did not occur in any patients during follow-up. The Parker score in patients seen at follow up was 4.3 (0-9). DISCUSSION-CONCLUSION: Locking compression plates associated with a mini-invasive surgical approach result in a high rate of union (35/36) with no significant misalignment (only 5/36 cases of misalignment of more than 5°), no refractures (n=0) and a low rate of mechanical failure (3/36) while allowing full weight bearing in most cases (20/36). Locking plates for periprosthetic femoral fractures allow patients to begin walking again, with stable intermediate term results.

Minimally-invasive fixation of distal extra-articular femur fractures with locking plates: limitations and failures.

Minimally-invasive fixation using a locking plate and early motion is normal practice. However, technical errors and pitfalls are common. This surgery has a set of rules that encompass both the mechanics of the internal fixation system and the implantation itself. If these rules are not strictly followed, alignment defects and/or early failure of the fixation can occur. We analysed four cases of clinical failure that were encountered after minimally-invasive distal femoral extra-articular fixation with locking plates. The following rules must be followed with this technique: extra-articular fracture, minimally-invasive approach, long plate alternating between locking screw and empty hole (five holes on either side of fracture), bi-cortical screws, placement of locking screws near a complex fracture but away from a simple fracture. Osteoporotic bone, obesity that interferes with the instrumentation, articular fracture, horizontal fracture line and surgeon experience are all limitations of this minimally-invasive technique.

Reversed anatomic distal femur locking plate for periprosthetic hip fracture fixation.

The incidence of femoral fracture on hip prosthesis is increasing. Plate fixation is the method of choice when the prosthesis is stable. In fracture with proximal extension, the quality of the bone fixation is critical and, despite the development of anatomic plates, may be endangered when there are too few proximal screws. To resolve this issue, we recommend using a reversed LCP™ anatomic distal femoral Less Invasive Stabilization System (LISS™) locking plate: e.g., a left distal femoral plate for femoral fracture on right-hip implant. This presents several advantages: minimally invasive surgery, the introduction of the plate being facilitated by the LISS™ ancillary; ease of locking, also thanks to the ancillary; and, above all, multiple proximal trochanteric fixation thanks to the form of this anatomic distal LISS™ plate, improving proximal bone fixation. The present technical note seeks to illustrate the interest of using a "reversed" plate, in terms of simplicity of fitting and quality of reduction and consolidation, while also specifying the associated limitations and tolerance.

Minimally-invasive internal fixation of extra-articular distal femur fractures using a locking plate: tricks of the trade.

Fractures of the distal femur are rare and occur in two distinct population categories: young patients after high energy traumas and elderly patients who fall from their full height, and often carry severe co-morbidities making especially difficult to manage theses complex injuries. In elderly patients the potential complications are numerous including infection, non-union and frequent function deterioration. We present a technique of minimally invasive internal fixation of the distal extra-articular femur using a locking plate and present the tricks of the trade to obtain successful reduction and achieve union. The hardware used includes plate fixation with a large fragment locking screw. This minimally invasive surgery combines stability of the internal fixation device with the principles of closed surgery, allowing early mobilization and immediate weight bearing to warrant good functional recovery.

Targeting device for intramedullary nails: a new high-stable mechanical guide.

One of the most demanding steps of an intramedullary nailing is the distal locking. The aim of this study is to evaluate clinically and prospectively a new targeting guide. Twenty-five patients were treated consecutively in two different trauma centres (level one and one general hospital) by two different surgeons who were instructed on using the new device. Reduction of the fracture, intramedullary nailing and proximal locking are performed according to standard procedures. Then the new targeting device is used for distal locking. Evaluations are focused on the time it takes to perform the distal locking, the duration of the irradiation exposure and the duration of the complete procedure. In terms of duration, our results are comparable to those reported in the literature but this new device has more advantages than any other system. This new device is fully mechanical and is solidly linked to the patient. It can be used with any existing radioscopic equipment in any hospital. The guide is manually adjustable out of the X-ray field avoiding the surgeon being irradiated. The procedure is easy to learn and reproducible.

[Osteosynthesis of per- and subtrochanteric fractures by blade plate versus gamma nail. A randomized prospective study]. / Ostéosynthèse des fractures per- et sous-trochantériennes par plaque angulée versus clou Gamma. Une étude prospective randomisée.

AIM: To compare clinical and radiological results in per- and subtrochanteric fractures' management with 90 degrees blade plate or Gamma nail fixation; an implant allowing early weight-bearing and fracture healing in correct position remains still difficult. METHOD: Between 1993 and 1995, 26 patients addressed to our Center for a Kyle IV [1] fracture were divided into 2 groups, one fixed with blade plate and the other with Gamma nail. The follow-up for all patients is 12 months. RESULTS: Gamma nail allows early weight-bearing in all patients, fracture healing is acquired at 4.2 months; an operative diaphyseal fracture needed conversion to a long Gamma nail. We observed a slight cut-out that didn't need reoperation. In the blade plate group, we noticed three femoral head necrosis without major flattening, two non-unions, one plate's breakage and two malunions; fracture healing is acquired at 6.3 months. The two non-unions and the plate's breakage didn't need reoperation because of low functional demand. CONCLUSION: We prefer Gamma nail in per- and subtrochanteric femoral fractures' management, it allows early and fast weight-bearing and fracture healing is acquired in all cases.

[Fractures of the tibial pilon. Long-term retrospective study of 51 fractures treated with open reduction and osteosynthesis]. / Les fractures du pilon tibial. Etude rétrospective à long terme de 51 fractures traitées par réduction sanglante et ostéosynthèse.

PURPOSE OF THE STUDY: Fracture of the tibial pilon is a rare injury and its treatment remains difficult. The aim of this study was to report the complications and long term results of internal fixation using a technique which respects soft tissues and in which little material was used. MATERIAL: From 1985 to 1990, 48 patients with 51 fractures of the tibial pilon were treated by open reduction and internal fixation. All patients were submitted to a clinical and radiological review. METHODS: Both the Rüedi/Allgöwer and the AO-classification were used and determined by standard X-rays. Surgical procedure was performed with a 2 or 3 1/3 tube AO-plates and the peroneus was always fixed if fractured. Intraoperative reconstruction was analyzed. Subjective and objective scoring were used according to Olerud and Molander and the ankle arthritis was scored according to the classification determined by the SOFCOT in 1992. RESULTS: A minimal follow-up of 1 year for all cases was obtained, based on our own files. Thirty-eight patients (40 fractures) were evaluated after an average period of 88 months (56 to 124 months). Five patients developed cutaneous infection, three developed deep infection and four developed superficial skin necrosis. One aseptic non-union necessitated reoperation after 14 months. Two ankles had joint fusion after 19 and 25 months respectively due to severe arthritis. In six cases infectious and non-infectious complications led to surgical revision. According to the Olerud and Molander score, 15 per cent of the results were excellent, 45 per cent were good, 30 per cent were fair and 10 per cent poor. DISCUSSION: Literature shows a wide range of results following this surgical procedure. This is due to the difference in the type of trauma, classification system used, material used for the internal fixation and method of evaluation. The classification system of Rüedi and Allgöwer is the most commonly used but has a rather subjective tendency, especially between type II and type III. Treatment is difficult, especially for comminutive fractures associated with soft tissue damage. In this case, open reduction and internal fixation could increase iatrogenic lesions. For this reason surgical procedure can be delayed for several days, little material is used and soft tissue manipulation is reduced to minimum. In other study reports, the use of external fixation with or without minimal internal fixation have produced less complications without improving long term results. CONCLUSION: Analysis and comparison of study reports are difficult because of the absence of consensus in classification system and evaluation methods. The AO-classification, apparently the most objective, will probably be more and more used in the future. Treatment must be adapted to the bony lesion and soft tissue damage. Open reduction and internal fixation must be reserved for a specific group of lesion.

[Acute ruptures of the Achilles tendon--apropos of 14 conservatively treated cases]. / Les ruptures fraîches du tendon d'Achille--A propos de 14 cas traités conservativement.

GOAL OF THE STUDY: To analyse the results of non surgical treatment (cast for 12 weeks) for complete and recent rupture of Achilles tendon. MATERIAL AND METHODS: We reviewed with an average follow up of 2 years 14 patients (14 ruptures). All patients evaluated subjective results on a linear scale. Objective results were given by clinical examination, ultrasonography and performance testing. RESULTS: Subjective results were excellent for 50% of cases, good for 29% and fair for 21%. Amyotrophy of the calf was always noted (mean 15 cm). The maximum force was reduced by 22% and the endurance by 47% in comparison with the healthy calf. All sportsmen but one were able to continue their sport as before. None of them had to change their job. DISCUSSION: The conservative treatment of fresh ruptured Achilles tendon by plaster cast for 12 weeks gives satisfactory results in comparison with surgical treatment followed by 6 weeks immobilisation. The results are not so good when compared to conservative or surgical treatment followed by immediate mobilisation. CONCLUSION: Conservative treatment by plaster cast for 12 weeks should be applied to non compliant patients or to patients who are not concerned by the functional results or unable to follow a programme of reeducation or to patients with chronic skin lesions.

[Epidermoid cancer of the esophagus: overview]. / Cancer épidermoïde de l'oesophage: mise au point.

Numerous extrinsic factors are involved in the pathogenesis of esophageal cancer. The disease exhibits clinical symptoms only at the advanced stage, often when no further curative possibilities exist; this delay is one of the main causes of the poor prognosis still associated with esophageal cancer. To secure early diagnosis, contrast GI series and endoscopy should be performed immediately whenever esophageal symptoms are present. Initial assessment of esophageal cancer should in any case include thoraco-abdominal scan. Bronchoscopy is indicated when the tumor is localized in the middle third of the organ. Surgery has long been considered the only valid treatment for esophageal cancer. However, the rule today is a multidisciplinary approach which offers either curative or palliative treatment designed to optimize therapy and minimize side effects. Promising results have recently been obtained with a combination of radiotherapy-chemotherapy followed by esophagectomy.