Outcomes of surgical treatments of spinal metastases: a prospective study.

BACKGROUND: Owing to recent advances in cancer therapy, updated data are required for clinicians counselling patients on treatment of spinal metastases. OBJECTIVE: To analyse the outcomes of surgical treatments of spinal metastases. METHODS: Prospective and multicentric study that included consecutively patients operated on for spinal metastases between January 2016 and January 2017. Overall survival was calculated with the Kaplan-Meier method. Cox proportional hazard model was used to calculate hazard ratio (HR) analysing mortality risk according to preoperative Karnofsky performance status (KPS), mobility level and neurological status. RESULTS: A total of 252 patients were included (145 males, 107 females) aged a mean 63.3 years. Median survival was 450 days. Primary cancer sites were lung (21%) and breast (19%). Multiple spinal metastases involved 122 patients (48%). Concomitant skeletal and visceral metastases were noted in 90 patients (36%). Main procedure was laminectomy and posterior fixation (57%). Overall, pain and mobility level were improved postoperatively. Most patients had normal preoperative motor function (50%) and remained so postoperatively. Patients "bedbound" on admission were the less likely to recover. In-hospital death rate was 2.4% (three disease progression, one septic shock, one pneumonia, one pulmonary embolism). Complication rate was 33%, deep wound infection was the most frequent aetiology. Higher mortality was observed in patients with poorest preoperative KPS (KPS 0-40%, HR = 3.1, p < 0.001) and mobility level ("bedbound", HR = 2.16, p < 0.001). Survival seemed also to be linked to preoperative neurological function. CONCLUSION: Surgical treatments helped maintain reasonable condition for patients with spinal metastases. Intervention should be offered before patients' condition worsen to ensure better outcomes.

Correction to: Outcomes of surgical treatments of spinal metastases: a prospective study.

The correct name of F. Saihlan should be F. Sailhan.

Ten-year survival and complications of total knee arthroplasty for osteoarthritis secondary to trauma or surgery: A French multicentre study of 263 patients.

BACKGROUND: Previous surgical procedures raise technical challenges in performing total knee arthroplasty (TKA) and may affect TKA outcomes. Survival rates of TKA done after trauma or surgery to the knee have not been accurately determined in large populations. The objectives of this retrospective study in 263 patients with TKA after knee trauma or surgery and a follow-up of 10 years were to assess survival, functional outcomes, and the nature and frequency of complications. HYPOTHESIS: Knee trauma or surgery before TKA increases the risk of complications and decreases implant survival. MATERIAL AND METHODS: Two hundred and sixty-three patients (122 [47%] females and 141 [53%] males) underwent TKA between 2005 and 2009 at nine centres in France. Mean age at surgery was 61 years. The patients had knee osteoarthritis secondary to a fracture (n=66), osteotomy (n=131), or ligament injury (n=66). Mean time from trauma or surgery to TKA was 145 months (range, 72-219 months). RESULTS: Major complications were infection (n=12, 4.5%), skin problems (n=8, 3%), and stiffness (n=8, 3%). Ten-year survival to implant exchange for any reason was 89%±2.8%. Flexion range increased by 2.5°±17° (p=0.02) to a mean of 110° (range, 30° to 140°); extension range increased by 4°±7° (p<0.001) to a mean of -1.19 (range, -20° to 0°). Of the 263 patients, 157 (60%) reported little or no pain at last follow-up. Mean postoperative hip-knee-ankle angle was 179°±3.2° (range, 171°-188°). CONCLUSION: TKA performed after knee injury or surgery carries a risk of specific complications (infection, skin problems, and stiffness) and may have a lower survival rate compared to primary TKA. LEVEL OF EVIDENCE: IV, retrospective cohort study.

Total knee arthroplasty after opening- versus closing-wedge high tibial osteotomy. A 135-case series with minimum 5-year follow-up.

INTRODUCTION: High tibial osteotomy (HTO) is effective in treating isolated medial osteoarthritis of the knee, but subsequent deterioration is inevitable, and total knee arthroplasty (TKA) is then an option. The present study sought to compare TKA following medial opening-wedge HTO (OW-HTO) versus lateral closing-wedge HTO (CW-HTO) in terms of intraoperative data and clinical results. The study hypothesis was that there is no significant difference in clinical results or complications in TKA following OW-HTO or CW-HTO. MATERIAL AND METHOD: A retrospective multicenter (9 centers) study was conducted for the French Society of Orthopedic Surgery and Traumatology (SoFCOT), including 135 TKAs following HTO (58 OW and 77 CW) at a minimum 5 years' follow-up. Mean interval between HTO and TKA was 134 months and was longer in case of CW-HTO (P<0.0001). Mean age at TKA was 65.4 years and older in case of CW-HTO (P=0.021). Tibial slope was greater in case of OW-HTO (P=0.024). Prior to TKA, 55.7% of patients could walk without canes, 98.4% found stairs difficult or impossible and only 19.1% could manage a walking distance greater than 1000m. Mean flexion was 110°; 54.2% of patients showed frontal knee stability and 87.8% sagittal stability; 60.1% had a mechanical axis in varus, without difference according to OW- or CW-HTO. RESULTS: Hardware was almost systematically removed (in 98.5% of cases): in the same step for OW-HTO (P=0.018) or often in 2 steps for CW-HTO. The primary approach was generally re-used (54.2%), but less frequently in the CW-HTO group (P=0.0004). Lateral or medial ligament release was not associated in respectively 78.2% and 79.7% of cases. The TKA implant was usually without stem (87.2%) and was fitted using a conventional technique (74.4%). At a mean 87 months' follow-up, 78.5% of patients could walk without canes, stairs were still difficult or impossible for 67%, and 74.1% could now walk further than 1000m; mean flexion was 110.5°. Overall, 91.5% of patients showed frontal knee stability and 98.2% sagittal stability, without difference according to OW- or CW-HTO. There were 15 complications within 3 months, more often in the OW-HTO group (12.3%) although not significantly, and with no difference in severity. Late complications comprised loosening (5.5%) and infection (3.6%) and were more frequent in the CW-HTO group (12%) (P<0.05). DISCUSSION: The study hypothesis was partially confirmed. The only technical differences concerned hardware removal, often performed in two steps in case of CW-HTO, and TKA approach, which differed from the primary approach in case of CW-HTO. Clinical results were comparable between OW- and CW-HTO, but late complications were more frequent in the CW-HTO group. LEVEL OF EVIDENCE: III; comparative retrospective study.

Operative treatment of early infection after internal fixation of limb fractures (exclusive of severe open fractures).

Early infection after open reduction and internal fixation (ORIF) of a limb bone is defined as bacteriologically documented, deep and/or superficial surgical-site infection (SSI) diagnosed within 6months after the surgical procedure. This interval is arbitrarily considered sufficient to obtain fracture healing. The treatment of early infection after ORIF should be decided by a multidisciplinary team. The principles are the same as for revision arthroplasty. Superficial SSIs should be differentiated from deep SSIs, based on the results of bacteriological specimens collected using flawless technique. A turning point in the local microbial ecology occurs around the third or fourth week, when a biofilm develops around metallic implants. This biofilm protects the bacteria. The treatment relies on both non-operative and operative measures, which are selected based on the time to occurrence of the infection, condition of the soft tissues, and stage of bone healing. Both the surgical strategy and the antibiotic regimen should be determined during a multidisciplinary discussion. When treating superficial SSIs after ORIF, soft-tissue management is the main challenge. The treatment differs according to whether the hardware is covered or exposed. Defects in the skin and/or fascia can be managed using reliable reconstructive surgery techniques, either immediately or after a brief period of vacuum-assisted closure. In deep SSIs, deciding whether to leave or to remove the hardware is difficult. If the hardware is removed, the fracture site can be stabilised provisionally using either external fixation or a cement rod. Once infection control is achieved, several measures can be taken to stimulate bone healing before the end of the classical 6-month interval. If the hardware was removed, then internal fixation must be performed once the infection is eradicated.

Internal fixation of intra-capsular proximal femoral fractures in patients older than 80 years: Still relevant? Multivariate analysis of a prospective multicentre cohort.

BACKGROUND: Arthroplasty is now widely used to treat intra-capsular proximal femoral fractures (PFFs) in older patients, even when there is little or no displacement. However, whether arthroplasty is associated with lower mortality and complication rates in non-displaced or mildly displaced PFFs is unknown. The objectives of this prospective study were: (1) to evaluate early mortality rates with the two treatment methods, (2) to identify risk factors for complications, (3) and to identify predictors of functional decline. HYPOTHESIS: Arthroplasty and internal fixation produce similar outcomes in non-displaced fractures of patients older than 80 years with PFFs. MATERIAL AND METHODS: This multicentre prospective study included consecutive patients older than 80 years who were managed for intra-capsular PFFs at eight centres in 2014. Biometric data and geriatric assessment scores (Parker Mobility Score, Katz Index of Independence, and Mini-Nutritional Assessment [MNA] score) were collected before and 6 months after surgery. Independent risk factors were sought by multivariate analysis. We included 418 females and 124 males with a mean age of 87±4years. The distribution of Garden stages was stage I, n=56; stage II, n=33; stage III, n=130; and stage IV, n=323. Arthroplasty was performed in 494 patients and internal fixation in 48 patients with non-displaced intra-capsular PFFs. RESULTS: Mortality after 6 months was 16.4% overall, with no significant difference between the two groups. By multivariate analysis, two factors were significantly associated with higher mortality, namely, male gender (odds ratio [OR], 3.24; 95% confidence interval [95% CI], 2.0-5.84; P<0.0001) and high ASA score (OR, 1.56; 95% CI, 1.07-2.26; P=0.019). Two factors were independently associated with lower mortality, with 75% predictive value, namely, high haematocrit (OR, 0.8; 95% CI, 0.7-0.9; P=0.001) and better Parker score (OR, 0.5; 95% CI, 0.3-0.8; P=0.01). The cut-off values associated with a significant risk increase were 2 for the Parker score (OR, 1.8; 95% CI, 1.1-2.3; P=0.001) and 37% for the haematocrit (OR, 3.3; 95% CI, 1.9-5.5; P=0.02). Complications occurred in 5.5% of patients. Surgical site infections were seen in 1.4% of patients, all of whom had had arthroplasty. Blood loss was significantly greater with arthroplasty (311±197mL versus 201±165mL, P<0.0002). Dependency worsened in 39% of patients, and 31% of patients lost self-sufficiency. A higher preoperative Parker score was associated with a lower risk of high postoperative dependency (OR, 0.86; 95% CI, 0.76-0.97; P=0.014). DISCUSSION: Neither treatment method was associated with decreased mortality or better function after intra-capsular PFFs in patients older than 80 years. Early mortality rates were consistent with previous reports. Among the risk factors identified in this study, age, preoperative self-sufficiency, and gender are not amenable to modification, in contrast to haematocrit and blood loss. CONCLUSION: Internal fixation remains warranted in patients older than 80 years with non-displaced intra-capsular PFFs. LEVEL OF EVIDENCE: III, prospective case-control study.

Proximal femoral fractures in centenarians. A retrospective analysis of 39 patients.

BACKGROUND: A corollary of the current population ageing in France is an increase in proximal femoral fractures (PFFs), particularly among centenarians. The outcomes of PFFs in centenarians in France are unknown. We therefore conducted a retrospective study of centenarians with PFFs both to assess: (1) assess clinical outcomes according to geriatric and trauma scores, (2) and to determine whether routine surgery is warranted. HYPOTHESIS: Morbidity and mortality in a single-centre cohort of centenarians with surgically treated PFFs are consistent with previous reports. MATERIAL AND METHOD: We retrospectively reviewed the data of 33 women and 6 men aged 100 years or over who were treated surgically for PFFs at a single-centre between 2008 and 2014. Of the 39 patients, 15 were living at home and 24 in an institution at the time of the injury. Mean (range) values were 3.30 (0-7) for the Parker Mobility Score, 5.84 (0-12) for the Katz index, and 7.46 (2-12) for the Mini Nutritional Assessment (MNA). Mean time from injury to surgery was 1.7 days (0-12). The 26 extra-capsular fractures were managed by internal fixation and the 13 intra-capsular fractures by hip arthroplasty (n=12) or screw fixation (n=1). RESULTS: After a mean follow-up of 23±14 months (6-60 months), 29 patients had died, including 3 within 48h, 10 within 3 months, and 15 within 1 year. Sequential mortality rates were 33.3% within the first 3 months, 26.9% from months 4 to 9, and 42.2% within the first year. Early dislocation occurred in 3 patients and surgical-site infection in 2 patients. Other complications were heart failure (n=1), confusional state (n=2), pneumonia (n=2), and pyelonephritis (n=2). DISCUSSION: A PubMed search identified five studies of PFFs in more than 10 centenarians, of which only 2 provided detailed information on postoperative general and local morbidity related to the surgical treatment. Our hypothesis was confirmed for 3-month and 1-year mortality rates, which were at the lower ends of previously reported ranges. Local complications related directly to surgery were considerably more common in our study. PFFs in centenarians carry a high risk of death. Despite the absence of a control group, our data support surgery as the best treatment option. LEVEL OF EVIDENCE: IV, retrospective study.

Microbial flora on cell-phones in an orthopedic surgery room before and after decontamination.

INTRODUCTION: Cell-phones are the typical kind of object brought into the operating room from outside by hospital staff. A great effort is made to reduce the level of potentially contaminating bacteria in the operating room, and introducing these devices may run counter to good practice. The study hypothesis was that cell-phones are colonized by several strains of bacteria and may constitute a source of nosocomial contamination. The main study objective was to screen for bacterial colonies on the surfaces of cell-phones introduced in an orthopedic surgery room. The secondary objective was to assess the efficacy of decontamination. MATERIAL AND METHOD: Samples were taken from the cell-phones of hospital staff (surgeons, anaesthetists, nurses, radiology operators, and external medical representatives) entering the operating room of the university hospital center orthopedic surgery department, Toulouse (France). Sampling used Count Tact® contact gel, without wiping the phone down in advance. Both sides of the phone were sampled, before and after decontamination with a pad imbibed with 0.25% Surfanios® Premium disinfectant. A nasal sample was also taken to investigate the correlation between Staphylococcus aureus in the nasal cavities and on the cell-phone. RESULTS: Fifty-two cell-phones were sampled. Before decontamination, the mean number of colony-forming units (CFU) was 258 per phone (range, 0-1,664). After decontamination, it was 127 (range, 0-800) (P=0.0001). Forty-nine cell-phones bore CFUs before decontamination (94%), and 39 after (75%) (P=0.02). DISCUSSION: Cell-phones are CFU carriers and may thus lead to contamination. Guidelines should be drawn up to encourage cleaning phones regularly and to reduce levels of use within the operating room.

Is the prognosis the same for periprosthetic joint infections due to Staphylococcus aureus versus coagulase-negative staphylococci? A retrospective study of 101 patients with 2-year minimum follow-up.

BACKGROUND: Staphylococcus aureus (SA) and Coagulase-negative staphylococci (CoNS) are often responsible for infections of total hip arthroplasty (THA) and total knee arthroplasty (TKA). One of the main differences between these two microorganisms is their virulence, with SA presumed to be more virulent; however, few studies have specifically investigated the impact of this virulence. This inspired us to carry out a retrospective study to evaluate whether the healing rate differed between SA and CoNS infections. HYPOTHESIS: We hypothesised that the healing rate is lower for SA prosthetic joint infections. MATERIALS AND METHODS: This was a retrospective study of 101 consecutive Staphylococcus infection cases that occurred between 2007 and 2011. There were 56 men and 45 women with an average age of 69 years (range 23-95). The infection was associated with TKA in 38 cases and THA in 63 cases. Thirty-two percent of patients had one or more comorbidities with infectious potential. In our cohort, there were 32 SA infections (31.7 %) and 69 CoNS infections (68.3 %) with 58 of the infections being methicillin-resistant (15 SA and 43 CoNS); there were 27 polymicrobial infections (26.7 %). RESULTS: With a minimum 24-month follow-up after the end of antibiotic treatment, the healing rate was 70.3 % overall (71 patients). The healing rate was 75 % in the SA group (24 patients) versus 68.1 % (47 patients) in the CoNS group (P = 0.42). CONCLUSION: Our hypothesis was not confirmed: the healing rate of SA prosthetic joint infections was not lower than that of CoNS infections. LEVEL OF EVIDENCE: III, retrospective case-control study.

Pre- and postoperative complications of adult forearm fractures treated with plate fixation.

INTRODUCTION: Adult forearm fractures account for 1-2% of all fractures of the limbs. The main objective of this retrospective multicenter study was to evaluate pre- and postoperative complications of forearm fractures. The secondary objective was to evaluate functional and radiological results of plate osteosynthesis for these fractures. MATERIAL AND METHODS: Between January 2008 and March 2014, 131 forearm fractures were reviewed retrospectively. Fractures were classified preoperatively according to the AO classification. Clinical outcomes were classified into four categories according to the Tschnerne and Oestern classification. Pre- and postoperative complications were sought systematically. RESULTS: Before surgery, 12 patients had neurological impairment (9%). At the last follow-up, nine patients had persistent neurological disorders (6.9%). Union of forearm fractures was obtained in 122 patients at 4.6 months on average (±2.6). Nine patients with nonunion were observed (6.9%) and five patients had radioulnar synostosis (3.8%). DISCUSSION: The frequency of neurological complications concomitant to forearm fractures is noteworthy. Similar cases with essentially irritative neurological disease have been reported in the literature, in particular for the ulnar nerve. Fracture nonunion is a relatively common complication: between 2 and 10% of cases depending on the study. LEVEL OF EVIDENCE: IV.

Distal radius fracture malunion: Importance of managing injuries of the distal radio-ulnar joint.

BACKGROUND: Distal radius malunion is a major complication of distal radius fractures, reported in 0 to 33% of cases. Corrective osteotomy to restore normal anatomy usually provides improved function and significant pain relief. We report the outcomes in a case-series with special attention to the potential influence of the initial management. MATERIAL AND METHODS: This single-centre retrospective study included 12 patients with a mean age of 35years (range, 14-60years) who were managed by different surgeons. There were 8 extra-articular fractures, including 3 with volar angulation, 2 anterior marginal fractures, and 2 intra-articular T-shaped fractures; the dominant side was involved in 7/12 patients. Initial fracture management was with an anterior plate in 2 patients, Kapandji intra-focal pinning in 5 patients, plate and pin fixation in 2 patients, and non-operative reduction in 3 patients. The malunion was anterior in 10 patients, including 2 with intra-articular malunion, and posterior in 2 patients. Corrective osteotomy of the radius was performed in all 12 patients between 2005 and 2012. In 11/12 patients, mean time from fracture to osteotomy was 168days (range, 45-180days). The defect was filled using an iliac bone graft in 7 patients and a bone substitute in 4 patients. No procedures on the distal radio-ulnar joint were performed. RESULTS: All 12 patients were evaluated 24months after the corrective osteotomy. They showed gains in ranges not only of flexion/extension, but also of pronation/supination. All patients reported improved wrist function. The flexion/extension arc increased by 40° (+21° of flexion and +19° of extension) and the pronation/supination arc by 46° (+13° of pronation and +15° of supination). Mean visual analogue scale score for pain was 1.7 (range, 0-3). Complications recorded within 2years after corrective osteotomy were complex regional pain syndrome type I (n=1), radio-carpal osteoarthritis (n=3), and restricted supination due to incongruity of the distal radio-ulnar joint surfaces (n=3). This last abnormality should therefore receive careful attention during the management of distal radius malunion. DISCUSSION: In our case-series study, 3 (25%) patients required revision surgery for persistent loss of supination. The main error in these patients was failure to perform a complementary procedure on the distal radio-ulnar joint despite postoperative joint incongruity. This finding and data from a literature review warrant a high level of awareness that distal radio-ulnar joint congruity governs the outcome of corrective osteotomy for distal radius malunion.

Peri-lunate dislocation and fracture-dislocation of the wrist: Retrospective evaluation of 65 cases.

INTRODUCTION: Peri-lunate wrist dislocations and fracture-dislocations are related to high-energy trauma. Prognosis is often compromised because of the complexity of the lesions. The purpose of this study was to assess outcomes of acute peri-lunate injuries and correlate them with the type of lesion and management. MATERIEL AND METHODS: A monocenter retrospective study has been conducted. Sixty-five patients (65 wrists) were reviewed. According to Herzberg's classification, there were 18 isolated peri-lunate dislocations and 47 peri-lunate fracture-dislocations - 27 with a scaphoid fracture and 20 with an intact scaphoid. The displacement was dorsal in 62 cases. All patients were treated surgically. RESULTS: At an average follow-up of 8 years (2-16) the average Cooney score was 66 points, quick-DASH score 21 points, and PRWE score 28 points. Pain score was 1.3 out of 10 points at rest and 4.3 out of 10 with effort. The flexion-extension arc was 96° with an average strength of 38kg (70±23% of opposite side). Radiographic analysis has shown decrease in carpal height, increase in ulnar translation, and DISI. Sign of wrist arthritis was found in 58.5% of the cases. The rate of osteonecrosis was 7.7%. Regional sympathetic painful syndrome was observed in 12%. In 26% of the cases a secondary surgery was needed. No influence has been found with the final results between fracture-dislocation and isolated dislocation, and delay of treatment. Osteochondral lesions observed at surgery (P=0.035), osteonecrosis at follow-up (P=0.017), and modification of the scapho-lunate angle (P=0.029) were correlated with the occurrence of osteoarthritis. DISCUSSION: Peri-lunate dislocation and fracture-dislocation represent severe wrist trauma with often numerous sequelae with follow-up: pain, stiffness, loss of strength, carpal instability and arthritis. Early diagnosis and anatomic reduction are prerequisite to a satisfactory functional result. Capsulo-ligamentous lesions must be repaired and fractures must be fixed. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Proximal ulnar fractures in adults: a review of 163 cases.

The aim of this study was to report the epidemiological characteristics and the experience of 5 departments of trauma, in France, in the management of fractures of the proximal ulna. 163 patients with fractures of the proximal ulna with a mean age of 49.9 years (range 16-97) were managed. The most common mode of injury was a motor vehicle collision (48%). 18% sustained associated injuries to the ipsilateral limb. Open fractures were present in 42 patients (25%). A total of 109 patients had a fracture of the olecranon, with the Mayo 2A and B types most frequently seen (66%). The patients were invited for clinical examination at a mean duration of 16 months, retrospectively. Validated patient-oriented assessment scores involving the Mayo Elbow Performance Index (MEPI) and the Broberg and Morrey score were evaluated. All patients had follow-up radiographs. The mean arc of elbow motion was 130° (70-150°). The mean MEPI was 91 (20-100) with good results in 23% and excellent results in 52% of the patients. The mean Broberg and Morrey score was 90 after isolated olecranon fracture, and decreased with the complexity of the lesion. 117 fractures (72%) healed with ulnohumeral congruity. 9 fracture non-unions occurred (6%). Although the fracture of the proximal ulna can be described in several classifications, none of them accommodate it satisfactorily, because of the complexity of the lesion. The coronoid process is the keystone for the stability of the elbow. It forms the anterior buttress with the radial head. Tension band wire fixation is by far the commonest technique of internal fixation used for the treatment of non-comminuted olecranon fractures. Dorsal plate fixation is a useful option by providing improved fixation of complex comminuted fractures and fracture-dislocations. The radiocapitellar joint has to be restored appropriately, preserving the radial head when possible and replacing it with a prosthesis otherwise. The lateral collateral ligament complex is commonly disrupted and usually can be reattached to its origin from the lateral epicondyle. In addition, a brief period of hinged external fixation should be considered.

Traumatic Floating Knee: A Review of a Multi-Centric Series of 172 Cases in Adult.

The traumatic floating knee in adults (FK) is a combined injury of the lower limb defined by ipsilateral fractures of the tibia and femur. The first publications emphasized the severity of injuries, the bad results after conservative treatment, the most severe functional outcome in case of articular fracture and the frequency of associated cruciate ligament injuries. The surgical management of FK has been highly modified according the improvement of the fracture fixation devices and the operative techniques. This retrospective multicentric observational study included 172 adults with a FK injury admitted in emergency in 5 different level I or II trauma centers. All the patients data were collected on an anonymized database. Results were evaluated by the overall clinical Karlström's score at latest follow-up. Fracture union was assessed on X-rays when at least 3 out of 4 cortices were in continuity in two different radiological planes. A statistical analysis was performed by a logistic regression method. Despite some limitations, this study confirms the general and local severity of this high-energy trauma, mainly occurring in young people around the third decade. A special effort should lead to a better initial diagnosis of associated ligamentous injury: a tear of PCL can be suspected on a lateral-ray view and a testing of the knee should be systematically performed after fixation of the fracture under anesthesia. Secondary MRI assessment is sometimes difficult to interpret because of hardware artifacts. The timing of fracture fixation is discussed on a case by case basis. However, a first femoral fixation is recommended except in cases of tibia fracture with major soft tissue lesion or leg ischemia requiring the tibia fixation first. Also a tibia stabilized facilitates the reduction and fixation of a complex distal femur fracture. The dual nailing remains so far for us the best treatment in Fraser I FK. Further prospective studies are needed to validate treatment algorithms, best fixation techniques in order to decrease the rate of complication and improve the functional outcome of floating knee injuries.

External fixation of distal femoral fractures in adults' multicentre retrospective study of 43 patients.

BACKGROUND: A multicenter cohort of 43 adults with distal femoral fractures (DFFs) managed with external fixation was evaluated to determine the potential of this treatment. PATIENTS AND METHODS: The patients were young adults (mean age: 39.6 years) with high-energy trauma; 12 had polytrauma and 41 multiple fractures. Most patients (38/43) had compound DFFs. Fracture types were A in 3 patients, B in 3 patients, and C in 37 patients. A tibio-femoral construct was required in 11 patients and a femoro-femoral construct in 32 patients. RESULTS: The normal femoral axis was restored within 5° in the coronal plane in 34 (79%) patients and in the sagittal plane in 22 (51%) patients. Axis restoration within 5° in both planes was achieved in 19 (44.7%) patients. After femoro-femoral external fixation, mean malalignment was 4.2° in the coronal plane and 8.6° in the sagittal plane; corresponding values after tibio-femoral external fixation were 1.3° and 8.6°. In 23 patients (of whom 1 was lost to follow-up), external fixation was intended as the only and definitive treatment; among them, 1 required amputation after a failed revascularization procedure, 10 achieved fracture healing within a mean of 21.2 weeks, 6 required conversion to another technique, and 5 underwent non-conservative procedures (total knee arthroplasty in 3 and arthrodesis in 2). In the remaining 20 patients, conversion to internal fixation was intended initially and performed within a mean of 4.7 weeks; 1 of these patients required amputation for ischemia, 3 did not achieve fracture healing, 12 achieved primary fracture healing, and 4 achieved fracture healing after repeated grafting (n=3) or osteotomy (n=1). At last follow-up (at least 1 year), the mean International Knee Society (IKS) Function Score was 67.3 and an IKS Knee Score of 68.5. Range of active flexion was 85.75° overall, 62.3° in the group with intended definitive external fixation and 101° in the group with intended conversion to internal fixation. Healing without complications was achieved in 10 (43%) in the former group and 12 (60%) in the latter group. CONCLUSION: Our data support provisional external fixation followed by early conversion to internal fixation in patients with extensively compounded DFFs; patients with multiple fractures requiring several surgical procedures; and polytrauma patients awaiting hemodynamic, respiratory, or neurological stabilization. LEVEL OF EVIDENCE: IV, retrospective study.

Outcomes of bipolar radial head prosthesis to treat complex radial head fractures in 22 patients with a mean follow-up of 50 months.

BACKGROUND: Radial head replacement is indicated to treat complex proximal radial fractures that are not amenable to internal fixation. HYPOTHESIS: Implantation of a bipolar radial head prosthesis after radial head excision ensures stability of the elbow and forearm, thereby promoting ligament healing and restoring elbow function. MATERIAL AND METHODS: Twenty-two patients managed with implantation of a bipolar radial head prosthesis (Guepar(®)) were evaluated after a mean follow-up of 50 months. The procedure was performed in the acute setting in 16 patients, including 13 with associated injuries; and at the stage of sequelae in 6 patients. RESULTS: Prosthesis removal was required in 4 patients. Of the remaining 18 patients, 14 (77%) had satisfactory Mayo Elbow Performance Score values, 14 (77%) little or no functional impairment, and 11 (61%) little or no pain. Mean motion arcs were 100° in flexion-extension and 143° in pronation-supination. Mean elbow strength in flexion and mean wrist strength were 67% and 86%, respectively, of those on the contralateral normal side. Radio-lucent lines were visible around the prosthesis in 5 patients, radial neck osteolysis in 10 patients, and capitellar erosion in 7 patients. Seven patients each experienced a complication. Early revision surgery to treat elbow instability was required in 6 patients. DISCUSSION: Outcomes after Guepar(®) bipolar radial head prosthesis implantation were disappointing in patients with complex radial head fractures seen in the acute or chronic setting. The associated injuries to bones and ligaments and the measures taken to repair them influence the prognosis. The complication rate is non-negligible and seems to increase over time. LEVEL OF EVIDENCE: IV, retrospective study.

Case report: Double nerve transfer of the anterior and posterior interosseous nerves to treat a high ulnar nerve defect at the elbow.

Double neurotization of the deep branch of ulnar nerve (DBUN) and superficial branch of ulnar nerve using the anterior interosseous nerve (AIN) and the recurrent (thenar) branch of the median nerve was first described by Battiston and Lanzetta. This article details the postoperative results after 18 months of a patient who underwent this technique using the posterior interosseous nerve (PIN) instead of the recurrent branch of the median nerve for sensory reconstruction. A 35-year-old, right-handed man suffered major trauma to his right upper limb following a serious motor vehicle accident. One year later, a pseudocystic neuroma of the ulnar nerve was evident on ultrasound examination and MRI. After the neuroma had been resected, the nerve defect was estimated at 8 cm. One and a half years after the initial trauma, with the patient still at M0/S0, we transferred the AIN and PIN onto the deep and superficial branches of the ulnar nerve respectively. Nerve recovery was monitored clinically every month and by electromyography (EMG) every three months initially and then every six months. At 18 months postoperative, 5th digit abduction/adduction was 28 mm. Sensation was present at the base of the 5th digit. The patient was graded M3/S2. Clear re-innervation of the abductor digiti minimi was demonstrated by EMG (motor conduction velocity 50 m/s). Given that the ulnar nerve could not be excited at the elbow, this re-innervation had to be the result of the double nerve transfer. Neurotization of the DBUN using the AIN produces functional results as early as 1 year after surgery. Using PIN for sensory neurotization is easy to perform, has no negative consequences for the donor site, and leads to good recovery of sensation (graded as S2) after 18 months.

Mechanical failure of the Coonrad-Morrey linked total elbow arthroplasty: A case report.

Semiconstrained (linked design) total elbow arthroplasty is indicated in a wide variety of cases. Long-term survival is better than with non-linked prostheses. However, mechanical failure of the hinge mechanism is a complication that may occur during follow-up. We report a case of failure of the axle assembly of a Coonrad-Morrey elbow prosthesis 8 years after implantation for nonunion of a supracondylar distal humerus fracture. Initial revision surgery included changing the axle and the polyethylene bushings. Revision surgery was necessary 1 year later when the axle failed again. A custom-designed locking axle had to be used to stabilize the hinge mechanism. After 3 years follow-up, the hinge was intact, there was no loosening of the components and function of the elbow was good.

The role of total elbow arthroplasty in traumatology.

UNLABELLED: Fractures of the distal humerus account for 5% of osteoporotic fractures in subjects older than 60 years. A history of osteoporosis, co-morbidities, and joint comminution make their management difficult. The therapeutic options are limited to functional treatments, osteosynthesis, or either partial or total arthroplasty. Functional treatment of distal humerus fractures in the elderly subject provide inconsistent results, often with persistence of pain with a stiff or unstable elbow. Osteosynthesis remains the reference treatment for these fractures, following the principle of stable and rigid osteosynthesis allowing early mobilization. However, joint comminution and a history of osteoporosis occasionally make it impossible to meet this objective, with a considerable rate of complications and surgical revisions. Total elbow arthroplasty remains an alternative to osteosynthesis with very satisfactory immediate results restoring a painless, stable, and functional elbow. These results seem reproducible and sustainable over time. The complication rate is not uncommon with an approximately 10% surgical revision rate. Elbow hemiarthroplasty remains to be validated in this indication. LEVEL OF EVIDENCE: V.

Locked plating for internal fixation of the adult distal femur: influence of the type of construct and hardware on the clinical and radiological outcomes.

INTRODUCTION: Distal femoral fractures are rare and serious. Along with traditional internal fixation, new, dedicated hardware have appeared (distal nails, locked plating). We report the results of a multicenter prospective study of these fractures treated with locked plating. HYPOTHESIS: The short-term results are satisfactory and related to the type of construct and the hardware used, with better results for elastic assemblies and titanium implants. MATERIALS AND METHODS: From June 2011 to May 2012, 92 patients, mean age 64 years, were included in 12 centres. The fractures were classified as follows: 44 type A, 7 type B, and 41 type C according to the AO classification. Thirteen fractures were open. The plates were uniaxial. The assemblies were elastic in 52 cases, rigid in 26, and unconventional in 14. RESULTS: Seventy-six patients underwent a radiological follow-up at 6 months and 66 patients had a clinical result evaluated at 1 year. The mean range of motion was 100° and the mean IKS score was 122. The bone union rate was 87% within 12 weeks. Seven valgus, two varus, ten flexion deformities, and three recurvatum greater than 5° were observed (19.5%). Revisions involved two cases with loss of fixation, five cases of infection, and one case of arthrofibrosis (requiring arthroscopic arthrolysis). Secondary bone grafting was carried out in seven cases (four successfully). No influence of the type of assembly or the hardware used was demonstrated. DISCUSSION: The results remain modest, underscoring the severity of these fractures. Neither the type of construct nor the hardware used influenced the radiological and clinical outcomes. The hypothesis was not confirmed. LEVEL OF EVIDENCE: Level IV prospective, non-comparative study.