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The aim of this study was to evaluate the neuromuscular structures at risk during modified anterior minimally invasive plating osteosynthesis technique (Belangero–Livani) for humeral shaft fractures. Eight fresh-frozen human specimens ranging from 38 to 82 years old were used. Specimens were positioned supine with the shoulder in 70° abduction and the forearm in full supination. Anterior minimally invasive plating osteosynthesis technique according to Belangero–Livani technique was performed in each specimen. Under radioscopic control, the plate was introduced in retrograde fashion through the subbrachialis path. Anatomical structures were inspected and different anatomical parameters were measured after dissection at the end of the surgical procedures. Measurements were performed using a high digital caliper. Statistical analysis was performed using the Pearson’s correlation coefficient test. A p value of

The purpose of this study was to develop a technique allowing a faster return to previous activities after surgical treatment of short transverse and oblique fractures of the diaphysis of the fifth metacarpal. It consisted of an anterograde and retrograde centromedullary double pinning connected. Our series included 40 patients of average age 25 years including 2 women. In 20 cases (group I), an anterograde centromedullary pinning with a 1.6- or 2-mm pin was performed followed by a 6-week orthosis and then 2-week self-education. In 20 cases (group II), an anterograde and retrograde centromedullary double pinning was performed using 2 1.5-mm pins connected by a connector (MetaHUS®, Arex™). A first pin was introduced into the canal antegrade, then the second retrograde. The 2 externalized pins were connected, and self-rehabilitation was encouraged. Mean tourniquet time was 14.75 min (group I) and 15.8 min (group II), respectively. At the last follow-up, the average pain was 0.35/10 and 0.2/10, the Quick DASH 0.68/100 and 0.57/100, the strength of the hand 94.65% and 94.35%, the active flexion MCP 98.5% and 99%, respectively. MCP active extension was 98.5% and 98.75%; the sick leave was 8.4 and 6.3 weeks. All fractures healed without recovery with 3 complications: 2 infections on pins, in each group, 1 CRPS1 (group I). Our results seem to show that the technique of anterograde and retrograde centromedullary double pinning connected in the treatment of short transverse and oblique fractures of the diaphysis of the fifth metacarpal gives results at least as good as the reference technique with a non-negligible socioeconomic advantage, a less time off work.

In the context of total hip arthroplasty (THA), there are several reasons that have motivated the development of short stems. It has been postulated that short stems allow a better conservation of the bone stock if compared to conventional stems. As far as we have knowledge, the quantitative loss of diaphyseal bone stock in patients with standard femoral stems has not been fully described. The aim of this study was to provide evidences about the thickness of the cortical bone at the diaphysis in patients who have undergone unilateral THA with Furlong® stems with a minimum follow-up of 18 years. A retrospective study of patients who underwent THA in a single hospital was performed. The inclusion criteria were patients who had undergone a non-cemented elective THA with a Furlong® stem, minimum follow-up of 18 years, and contralateral femur and hip without history of previous surgical procedures. The follow-up analysis was performed by means of radiological examinations performed at the last follow-up visit. Data related to the sex, age at surgery and adverse events registered during the follow-up were gathered. The cortical thickness index (CTI) and cortical thickness (CT) assessed at the last follow-up visit in anteroposterior pelvic X-rays were analyzed, both in the operated hip and in the non-operated hip (which was used as control). Calibration of the measurements was done by means of using the circumference of the head of the THA. The total number of patients who met the inclusion criteria was 22. There were 14 women and eight men. There were 12 left hips. The mean age at the time of surgery was 59.32 ± 6.83 (range 50–70) years. The mean follow-up was 20.86 ± 1.90 (range 18–24) years. The CTI was found to be 11.93% greater in the non-operated hips. The CT measured at 3 cm and 6 cm from lesser trochanter, and at 9 cm from the greater trochanter, was found to be 21.64%, 15.33% and 18.73% greater in the non-operated hips, respectively. After a minimum of 18 years from the implantation of a Furlong® stem, the bone density that surrounds the implant seems to involve a cortical bone ten percent less thick than the cortical bone of the non-operated contralateral side. With this stem, the cortical zones with less CT seem to be the lateral cortex at 9 cm from the greater trochanter, and the medial cortex at 3 and 6 cm from the lesser trochanter. III, retrospective case–control study.

Aneurysmal bone cysts of small bones of hands are rare and pose diagnostic and therapeutic challenge. We report a case of aneurysmal bone cyst of fourth metacarpal bone in a 14-year-old boy who presented with history of pain and swelling for 6 months duration. Radiograph and magnetic resonance imaging revealed a fusiform swelling involving the diaphysis and the distal metaphysis of the fourth metacarpal bone without any cortical breach. The physeal plate was not involved. Histopathological finding confirmed the diagnosis to be aneurysmal bone cyst. The patient was treated with marginal resection of the tumour preserving the articular surface by retaining the epiphysis and the bony defect was reconstructed with autologous fibular strut graft. One-year follow-up revealed an excellent incorporation of the graft with no evidence of local recurrence and also excellent range of motion of the hand. Nonvascularized fibular strut graft is easy to harvest and provide an excellent functional outcome when used as intercalary autograft after excision of aneurysmal bone cyst of hand.

Revision hip arthroplasty can sometimes be very challenging due to poor proximal bonestock following multiple revisions, bone resorption, infection or peri-prosthetic fracture. The challenge for the surgeon is to achieve fixation of the implant distally in healthy bone, yet allow bone in-growth proximally to encourage regeneration of the deficient femur. We present our early experiences with a fully hydroxyapatite coated modular long stems with distal screw locking (REEF, Depuy) in difficult revision scenarios. A total of 21 patients with a mean age of 68 (range 37–86) were followed up for a mean period of 19 months (9–36 months). Revision was performed for aseptic loosening with severe proximal bone loss in 14 cases (67%), peri-prosthetic fractures in 6 cases (28%) and 1 case with infection (5%). Oxford hip score was determined for each patient. Radiographs were assessed for the formation of spot welds, cortical hypertrophy, radiolucent lines, subsidence of implants, calcar resorption and heterotopic ossification. One patient underwent re-revision due to initial undersizing of the stem. Radiological review of all the femoral components, including the one re-revision showed stable bony in-growth and no radiolucent lines in any zone. The incidence of spot weld formation and cortical hypertrophy was highest in zone 6. One patient had persistent thigh pain and subsidence of 2 cm occurred in one case (5%). There were no dislocations, infections or calcar resorption. Three patients developed Grade 1 and three patients developed Grade 2 heterotopic ossification. Improvement in stem design, surface coating, distal locking and modularity allow independent fitting of the diaphysis and metaphysis, adjustment of length, offset and version to facilitate more biological reconstruction of proximal femur. Early results with this stem in salvage revisions appear promising.

The following is a description of a slightly frequent pattern of fracture–dislocation of ankle, which is not catalogued as the habitual classifications, providing clinical and radiological images of the injury and the applied treatment. A 30-year-old patient suffers entorsis of the left ankle by a forced mechanism of external rotation and supination. The initial radiological study shows tibio-astragaline dislocation, with the tibia intact, rupture of the tibiofibular syndesmosis and fracture of the medial 1/3 of the fibular diaphysis. It is operated by performing a percutaneous fixation of the syndesmosis with two tricortical screws. The deltoid ligament shows the complete breakage, as well as the presence of a detached small bone fragment of the posterior malleolus. The deltoid ligament is sutured, and the small osseous fragment of the posterior malleolus is removed. Recovery is uneventful and in 6 months after the injury, the patient returns to normal mobility without pain. In conclusion, the pattern of the fracture–dislocation of the ankle described is very rare, having found only one similar case in the literature, with the difference that we obtained the closed reduction of the dislocation and posterior stabilization with percutaneous fixation by two tricortical screws.

The authors report on more than 10 years’ experience of using a cementless femoral stem, with a two-piece modular design, for indications of primary prosthetic replacement. One hundred and sixty-five prostheses, inserted between 06/11/1991 and 31/12/1994, were reviewed. No patient was lost to follow-up. The probability of 10-year survival of these hip prostheses was assessed using the actuarial Kaplan–Meier method (the endpoint was revision of the arthroplasty regardless of the reason: failure of the femoral or acetabular component, fracture of one piece of the implant etc.). The mean age of the 165 patients (84 women, 81 men) was 64 years. The clinical results were excellent or good in 87.2% of hips. There was no instance of post-operative thigh pain (apart from one case), because of the primary stability of the hydroxyapatite-coated metaphyseal part where stress transmission occurs, while the diaphyseal part, selected in accordance with requirements and smaller in diameter than the femoral canal, remained free in the diaphysis. No significant difference in the results was noted in accordance with the pattern of femoral anatomy encountered; however, the cylindrical femur yielded slightly inferior results (PMA score). Radiological follow-up showed that femoral fixation had been obtained, generally accompanied by obvious signs of bone fixation (endosteal ossification, radiolucencies indicating condensed bone in the smooth zone). A high number of cortical changes was not noted. Two stems were the cause of revision surgery, one because of thigh pain without sealing, the other because the stem fractured. Six acetabular implants were removed without interfering with the femoral stem, because of localised osteolysis around an expandable peg. Two other acetabular implants were replaced: one because poor positioning resulted in recurrent luxation and the other for premature wear of the polyethylene after 7 years. The grounds for revision were failure of the acetabular implant in 8 cases out of 10. Thus, there is sufficient justification for the use of this modular two-piece stem, which has fulfilled its purpose in the majority of patients, enabling us to extend with confidence indications for the cementless stem to all the anatomical types of femur encountered. Our series of patients included almost 78.7% of what are known as “normal” femurs, but in the remaining cases (21.3%) or in more than one in five instances, the modular stem made it possible to extend the indications for a cementless prosthesis to all the patterns of femur encountered, in particular to young adults, who often have femoral dysplasia or a cylindrical femur. The survival curve reflects the life of the implant: implant survival is 96.3%. If acetabular revisions are not included it is 98.8%. Conclusions: A modular system then, consisting of a metaphyseal and diaphyseal part, appears to be a first-rate component which optimises the indication for implantation of a cementless femoral prosthesis in order to obtain the correct performance of a medical service as the survival curve demonstrates.

Femoral involvement is frequently observed in bone metastases. Intramedullary nailing is a common technique for prophilactic stabilisation of femur when diaphysis or metadiaphysis are involved. Reconstructive nailing is currently used in the treatment of subtrochanteric involvements. The aim of this study is to evaluate results of contemporary femoral shaft and subtrochanteric or femoral neck metastases treated with long proximal femoral nail. A consecutive series of 27 impending or complete femoral fractures due to metastastic localisation treated with reconstructive nailing was analysed in this study. Indication to prophilactic stabilisation was defined according to Mirel’s criteria; preoperative planning included MRI, which showed the contemporary involvement of subtrochanteric region or neck also in the cases of shaft localisations. A long titanium proximal femoral nail with one distal screw inserted in a static mode was used in all patients. Improvement of the quality of life, with no mechanical problems (screw breakage or implant failure), was observed in this series. These results suggest that reconstructive nailing using a long proximal femoral nail may be considered a useful strategy for the treatment of diaphyseal and metaphyseal femoral metastatic lesions.

The objective of this study was to evaluate bony healing and predict factors affecting bony healing of femoral fractures treated with interlocking nailing (ILN) in static or dynamic conditions, and in reamed or unreamed procedures. Seventy-four femoral fractures (69 patients) were initially stabilized with ILNs in static condition. Among these fractures, ten static ILNs were dynamized after approximately 6 (median 6.4, range 1–13) months because of poor fracture healing. Reamed ILNs were performed for 55 fractures and unreamed ILNs for 19 fractures. Clinical and roentgenograhic processes were analyzed with emphasis on whether or not ILNs were dynamized. To evaluate any significant contributing factors affecting the nonunion of femoral shaft fractures treated with ILNs, logistic regression analysis was done. The union rates of static ILNs and dynamized ILNs were 92% (59/64) and 70% (7/10) respectively, but there was no significant difference between them. Five nonunions were seen in reamed ILNs and three in unreamed ILNs. The predictive logistic regression equation for nonunion was as follows: Log 1-p/p=1.05 −1.20 × AO/ASIF fracture grade in the femur −3.07 × existence of multiskeletal trauma in lower extremity + 0.06 × age −1.11 × smoking history −0.3 × existence of polytrauma −0.626 × the severity of soft tissue injury (p=0.002; each variable in the above equation was arranged according to the significant order). Among the variables, AO fracture grade (type C) in the femur and existence of multiskeletal trauma in lower extremity were significantly related to nonunion. Static ILN in most femoral shaft fractures does not inhibit the process of fracture healing. The following associated skeletal lesions were our concerns for nonunion and broken nail in static or dynamic ILNs: (1) C-type femoral fracture; and (2) existence of multiskeletal trauma, such as double lesions in the ipsilateral femur, floating knee injury, and bilateral femoral fractures.

In order to develop a biodegradable pin for diaphyseal femoral fracture fixation, polylactide acid (PLA) pins were implanted in the femoral bone of rats. A distal diaphyseal fracture was performed. Union and tissue reaction to PLA pins versus stainless steel pins was studied after 15 days, and 1, 2 and 6 months of implantation. PLA and stainless steel pins induced the same union and a similar tissue reaction during the 6-month period. Biocompatibility of material was satisfactory.

We evaluated the functional outcome of 12 femoral fractures treated using retrograde intramedullary nailing via an intercondylar approach. Patients were 9 men and 3 women with an average age of 39.4 years (range, 16–69 years). The follow-up period was 13–185 months, with an average follow-up of 95 months. Functional outcome was assessed by the knee-rating system of the Hospital for Special Surgery (HSS) and Neer's criteria. The average score was 76 points (44 –100 points) by HSS, and 77 points (36–100 points) by Neer's criteria. The outcomes over good results were seen in 67% (8/12) and 58% (7/12), according to respective rating system. Although retrograde nailing for the femoral fractures is useful method, it is still problematic about its efficacy on the basis of our acceptable rate.

Osteochondroma, the most common benign tumor, is very often diagnosed as an incidental finding on radiographs obtained for other purposes. The World Health Organization (WHO) defines osteochondroma as a cartilage-capped bony projection on the external surface of a bone. Whether sessile or pedunculated, the medullary canal of the stalk and the bone are in continuity by definition. Most are asymptomatic, but they can cause mechanical symptoms depending on their location and size. Symptomatic lesions should be excised completely. Usual site of origin is metaphysis, we report a solitary diaphyseal exostosis of femur in this case report.

Arthritis Arthritis of the hip in children and adolescent can induce lesions of the articular cartilage and severe handicap. When conservative surgical methods are without benefit, total hip arthroplasty should be an alternative solution. Indications Chronic pain, abnormal social life and scolarity, stiffness and impossibility for osteotomies are the main criteria to decide and to choose for an arthroplasty.Two main groups of etiology are as follow * group I concerns rhumatologie arthritis. Arthroplasty is decided with pediatricians, physiotherapists… Other joints are often involved and post-operative cares need intensive physiotherapy. Femoral head necrosis of renal disease and sickle cell disease belong to this group.* group II concerns sequelae of previous femoral osteotomy: septic osteoarthritis, severe stiffness, sequelae of hip dislocation, necrosis of slipped capital epiphysiolysis…Since 1990, Dr J.L. Jouve has operated on 11 hips in patients aged for 14 to 20. Prosthesis used were custom made, Symbios, Switzerland.Results group I: The custom made in this group is interesting because it is obvious to maintain the largest bony pool and to avoid to ream the metaphysis and diaphysis. It is also necessary to thinck in advance for further procedure because these patients are young. Technical surgical approach is without any particularity, no case of fracture was noticed. Post-operative weight-bearing was delayed for 45 days. With a short follow-up of 2 years, results are excellent.Results group II: The custom made is necessery in these cases with an abnormal morphology of the proximal femur and narrow canal following earlier femoral osteotomies. Immediate results are also excellent. Conclusion Hip arthroplasty with custom made is a nice procedure when other surgical treatments are not possible. But further studies are necessary with a larger follow-up.Tumors Osteosarcoma and Ewing's sarcoma needs sometimes wide resections of the proximal femur and reconstruction of the hip joint. In our experience and ISOLS' series, it seems that following data are favourable: - cemented complete prosthesis of the femur resected and no allograft, - excellent reconstruction of the muscles of the hip: extensors, abductors and fascia lata, without to try a fixation of these muscles on the prosthesis - use of an acetabular mobile cup to preserve further surgery with, for exemple, an acetabular arthroplasty. Two cases of Ewing's sarcoma are presented, girls aged 15 and 12.Length of the resection was 23 and 19 cm. Post-operative results are good.

The use of a reamed intramedullary nail allows the immediate correction and stabilisation of deformity in diaphysis of the femur. Passing a guide wire after a femoral diaphyseal osteotomy can prove to be difficult, particularly if the medullary canal has been narrowed or obliterated by bone re-modelling after fracture repair. We present a technique to allow safe and accurate guide-wire passage.

The chondro-epiphysis designates the articular and growth structure located at the extremities of a long bone. Two growth structures belong to the chondro-epiphysis: the disc shaped growth plate and the epiphyseal ossification center limited by a spherical growth cartilage. The growth plate is connected to the metaphysis by the perichondrial ring. The micro-structure of any growth plate shows a same cellular architecture, disposed in 5 layers and 3 zones. The zone of growth consists of a resting layer and a palisading layer with cell columns on top of which are the germinal cells. The zone of maturation is caracterized by a cellular hypertrophy, responsible for its mechanical weakness. The zone of transformation shows a degeneration layer and a calcification front. The growth plate has an axial cellular architecture and produces a linear growth oriented towards the diaphysis. On the other hand, the growth cartilage of the epiphyseal ossification center produces a multidirectional growth oriented towards the center of the nucleus.

Management of femoral shaft fractures in association with hip implants in situ is a difficult and complex problem. We present here our experience of nine periprosthetic femoral fractures treated successfully with open reduction and internal fixation using the Dall-Miles plate and cable system. We recommend this system for fixation of the type 3 fractures using a minimum of three proximal cables and three distal cables with supplementary screws.

we report a rare injury in a 32-year-old man victim of a high-energy motor vehicle accident who sustained a posterior hip dislocation with concomitant ipsilateral fractures of both the femoral head and femoral shaft. Closed reduction of the hip was attempted but failed. Surgical approach was necessary to reduce the hip and then femoral nailing was performed. The femoral head fragment was neglected. The patient died after 2 days of neurological complications. Combination of posterior hip dislocation with ipsilateral femoral shaft and head fractures is unusual.

The author has studied 21 cases of bovine xeno-grafts in human orthopaedic and trauma surgery. The indications were benign tumours (filling of defects with or without structural support), osteotomies for lengthening or passive correction of the limb (support and filling of defects), tibial tubercle elevation and some trauma cases, particularly complex fractures of the lateral tibial plateau. The study showed a lack of graft resorption, no matter the site of implantation. The graft was more or less incorporated according to the site. It incorporated well in the traumatised epiphysis, incompletely in short or flat bones and in the metaphyseal zone, and poorly in the diaphysis. Histological studies were made of 2 cases with follow-up of 2 and 5 years. They both showed a fibrous interface, discrete graft resorption with no sign of consolidation. Without considering the risks of contamination (prion or other), the author rejects this type of graft from a biological view point. Out of the 21 cases, we can however confirm the good mechanical hold of the bovine xenografts, whatever their site of implantation. In conclusion, it seems that the only and rare indications which remain are purely mechanical in the attempt to substitute bone which could add mechanical qualities which are sometimes necessary for good biological results with bone substitutes in osteosynthesis.

Fractures of the neck of the radius (Mason’s type IV) are rarely seen in the adult although they are the most frequent in the child. There is no satisfactory treatment at the present time and the authors present 2 cases treated by intramedullary nailing with good results. This technique was described by Metaizeau and al for the child. The first case was a woman 46 years old presenting a dislocation of the left elbow with a radial neck fracture Mason’s type IV. The angulation between the radial head and the diaphysis was 55°. The dislocation was spontaneously reduced and an intramedullary nailing was performed on the radial neck fracture. Six months later the mobility of the elbow was normal except 10° loss of extension. The X-rays showed a radial head with no evidence of necrosis, and no residual angulation. The second case is a 25-year-old man with a Mason’s type IV radial neck fracture. The angulation was 50°. At 6 months of follow up the elbow still had 15° loss of extension. The X-rays appearances were the same that for the first case. The procedure is detailed. The entry point is at the distal metaphysis. A kirschner wire is curved at its extremity and pushed into the medullary canal. The radial head is pinned by the sharp curved extremity of the wire. A rotating motion of the wire allows reduction and fixation of the fracture. The authors experience and the 6 cases presented by Keller shows that intramedullary nailing seems a good solution for fixation of the radial neck fractures.

The present work introduces a method of screw fixation of femoral neck fractures in the presence of osteoporosis, according to an original concept of the establishment of two supporting points for the implants and their biplane positioning in the femoral neck and head. The provision of two steady supporting points for the implants and the highly increased (obtuse) angle at which they are positioned allow the body weight to be transferred successfully from the head fragment onto the diaphysis, thanks to the strength of the screws, with the patient’s bone quality being of least importance. The position of the screws allows them to slide under stress with a minimal risk of displacement. The method was developed in search of a solution for those patients for whom primary arthroplasty is contraindicated. The method has been analysed in relation to biomechanics and statics. For the first time, a new function is applied to a screw fixation—the implant is presented as a simple beam with an overhanging end.