Vascular complication after percutaneous femoral cerclage wire.

Cerclage wire is an effective fracture fixation method. However, its mechanical benefits are countered by local ischemia. Its efficacy for treating femoral periprosthetic fractures has been demonstrated since femoral fixation is possible even there is a stem in the diaphysis. It securely holds the proximal femur typically with an additional plate. The development of minimally-invasive surgery with plate fixation has led to the cerclage wire being inserted percutaneously. Here, we report on a case of secondary femoral ischemia following percutaneous cerclage wire of a periprosthetic femoral fracture. This was a Vancouver type B1 fracture. On the 3rd day after admission, minimally-invasive fixation with a femoral locking plate was performed with five cerclage wires added percutaneously. During the immediate postoperative course, the patient developed ischemia of the operated leg that required vascular surgery after confirmation by CT angiography. An arterial stop was visible with deviation of the superior femoral artery, which was not properly surrounded by the cerclage wire. The latter pulled perivascular tissues towards the femur. When combined with reduced arterial elasticity due to severe atherosclerosis, it resulted in arterial plication. The postoperative course was marked by multiple organ failure and death of the patient. Percutaneous surgery is an attractive option but has risks. The presence of severe atherosclerosis is a warning sign for loss of tissue elasticity. This complication can be prevented by preparing the bone surfaces and carefully positioning the patient on the traction table to avoid forced adduction. The surgeon must also be familiar with alternative techniques to cerclage wire such as polyaxial screws and additional plates.

Ankle fusion in hemophilic patients.

INTRODUCTION: Hemophilic arthropathy is painful and disabling. We report a retrospective study of ankle fusion with intra- and peri-operative clotting factor perfusion. The objective was to assess the efficacy of maintaining perioperative clotting factor rates close to 100%, and report long-term results. The study hypothesis was that results would be good, without early hemorrhagic complications. MATERIAL AND METHOD: Between 2000 and 2013, 12 ankle fusions were performed in 9 patients, with a mean age of 39years (range, 19-58years). Anti-hemophilic factor perfusion was controlled by the reference physician of the Regional Hemophilia Treatment Center. Clinical AOFAS and Olerud scores and the Pettersson radiologic score were used for assessment. Mean preoperative AOFAS score was 22 (range, 2-55) and mean Olerud score 7 (range, 5-12). Mean preoperative factor VIII concentration was <1% (range, <1-3%). RESULTS: Mean follow-up was 8years (range, 2-16years). Mean AOFAS score at follow-up was 69 (range, 35-92) and mean Olerud score 70 (range, 30-100). Improvement mainly concerned the Pain dimension. Statistical analysis found a significant difference between pre- and post-operative clinical scores (AOFAS, P=0.004; Olerud, P=0.004). Mean factor VIII concentration at surgery was 90% (range, 24-117%), and 109% (range, 75-152%) the day following surgery. There were no cases of hematoma or surgical site infection. Radiologic fusion was systematic at a mean 3.5 months (range, 3-4months). CONCLUSION: The study hypothesis was confirmed. Ankle fusion in advanced hemophilic arthropathy improved function and quality of life. Perioperative clotting factor perfusion contributed to these good results, providing supplementary prevention of hemorrhagic risk. LEVEL OF EVIDENCE: IV, retrospective 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.

What are the risk factors for dislocation in primary total hip arthroplasty? A multicenter case-control study of 128 unstable and 438 stable hips.

INTRODUCTION: Dislocation after total hip arthroplasty (THA) is a leading reason for surgical revision. The risk factors for dislocation are controversial, particularly those related to the patient and to the surgical procedure itself. The differences in opinion on the impact of these factors stem from the fact they are often evaluated using retrospective studies or in limited patient populations. This led us to carry out a prospective case-control study on a large population to determine: 1) the risk factors for dislocation after THA, 2) the features of these dislocations, and 3) the contribution of patient-related factors and surgery-related factors. HYPOTHESIS: Risk factors for dislocation related to the patient and procedure can be identified using a large case-control study. PATIENTS AND METHODS: A multicenter, prospective case-control study was performed between January 1 and December 31, 2013. Four patients with stable THAs were matched to each patient with a dislocated THA. This led to 566 primary THA cases being included: 128 unstable, 438 stable. The primary matching factors were sex, age, initial diagnosis, surgical approach, implantation date and type of implants (bearing size, standard or dual-mobility cup). RESULTS: The patients with unstable THAs were 67±12 [37-73]years old on average; there were 61 women (48%) and 67 men (52%). Hip osteoarthritis (OA) was the main reason for the THA procedure in 71% (91/128) of the unstable group. The dislocation was posterior in 84 cases and anterior in 44 cases. The dislocation occurred within 3 months of the primary surgery in 48 cases (38%), 3 to 12 months after in 23 cases (18%), 1 to 5years after in 20 cases (16%), 5 to 10years after in 17 cases (13%) and more than 10years later in 20 cases. The dislocation recurred within 6 months of the initial dislocation in 23 of the 128 cases (18%). The risk factors for instability were a high ASA score with an odds ratio (OR) of 1.93 (95% CI: 1.4-2.6), neurological disability (cognitive, motor or psychiatric disorders) with an OR of 3.9 (95% CI: 2.15-7.1), history of spinal disease (lumbar stenosis, spinal fusion, discectomy, scoliosis and injury sequelae) with an OR of 1.89 (95% CI: 1.0-3.6), unrepaired joint capsule (all approaches) with an OR of 4.1 (95% CI: 2.3-7.37), unrepaired joint capsule (posterior approach) with an OR of 6.0 (95% CI: 2.2-15.9), and cup inclination outside Lewinnek's safe zone (30°-50°) with OR of 2.4 (95% CI: 1.4-4.0). DISCUSSION: This large comparative study isolated important patient-related factors for dislocation that surgeons must be aware of. We also found evidence that implanting the cup in 30° to 50° inclination has a major impact on preventing dislocation. LEVEL OF EVIDENCE: Level III; case-control study.

Tibiofemoral syndesmosis injury treated by temporary screw fixation and ligament repair.

INTRODUCTION: Tibiofemoral syndesmosis injuries are common but have not been extensively researched. The primary objective of this study was to evaluate the outcomes after temporary screw fixation with ligament repair of these injuries. The secondary objective was to look for factors that could impact these outcomes. We hypothesised that this double fixation (screw+suture) would lead to good outcomes with minimal secondary opening of the syndesmosis upon screw removal. MATERIAL AND METHODS: This was a retrospective study of 285 patients with a tibiofemoral syndesmosis injury (01/2004-12/2011) who were treated by temporary tricortical or quadricortical screw fixation and ligament repair. The operated leg was unloaded for 6-8 weeks postoperative with the patient wearing a walking cast. The screw was removed in all patients before weight bearing was allowed. At follow-up, the range of motion, return to sports, pain, and functional scores (AOFAS and OMAS) were determined, and a radiological assessment was performed. RESULTS: One hundred twenty-six patients were reviewed after a mean follow-up of 5.9±5.7years (2.9-10.5). Mean plantarflexion was 95% of the contralateral side and mean dorsiflexion was 93%. Return to sports occurred after a mean of 10weeks; 83% of patients returned to their pre-injury level of participation. Pain on VAS was 0.8/10 on average. The mean AOFAS and OMAS scores were both above 90 points. At the review, 4% of screws had broken. Diastasis was found in 5.6% of cases, osteoarthritis in 6.3% and an osteophyte in 11.1% of cases, but with no clinical repercussions. No risk factors were identified. DISCUSSION AND CONCLUSION: Treatment by temporary screw fixation and ligament repair leads to good objective results, confirming our hypothesis. However, there is little published data and no consensus on the fixation method or the need to remove the screw. LEVEL OF EVIDENCE: IV, retrospective, non-comparative.

Villonodular synovitis of the ankle. Analysis of the risk of recurrence.

INTRODUCTION: Villonodular synovitis (VNS) is a rare disease with an incidence of 1.8 per 1,000,000 inhabitants. VNS of the ankle has seldom been described and evaluated given its extreme rarity (2.5% of VNS cases). It presents an 11% recurrence rate. We report a continuous retrospective series with the main objective of clinically and radiologically evaluating these ankles searching for any risk factors of recurrence. At revision the study's main endpoint was the existence of local recurrence (radiological and clinical) and the secondary endpoint was the existence of tibiotalar osteoarthritis. The working hypothesis was that recurrence could be subclinical, warranting systematic imaging studies during follow-up. MATERIAL AND METHODS: The study was retrospective, conducted on seven patients (six males) whose mean age was 42 years treated over a period of 9 years (two diffuse forms and five localized forms). The initial treatment consisted in synovectomy via the conventional approach. Four patients also received adjuvant isotopic synoviorthesis treatment. The revision was clinical (MMTS, AOFAS, and OMAS scores) and radiological (standard and MRI) to evaluate the joint after-effects and search for recurrence. RESULTS: Six patients were seen at a mean 6.5 years of follow-up. One case of early recurrence (4 years) was noted, with a major clinical manifestation because it was associated with joint destruction requiring arthrodesis, and one case of late asymptomatic recurrence (9 years), diagnosed radiologically on the follow-up MRI. The functional results remained good at follow-up (MMTS 77%, AOFAS 71, OMAS 71). Five of the six patients returned to their daily activities. At revision, no sign of osteoarthritis was observed. No risk factor for recurrence was demonstrated. DISCUSSION/CONCLUSION: The hypothesis was confirmed with the existence of asymptomatic recurrence at revision, underscoring the value of systematic MRI at follow-up. Other than major joint destruction, the prognosis remains good even in case of recurrence. The literature emphasizes the existence of an initial diffuse form and partial surgical resection as risk factors of recurrence. None of the reports in the literature has proven that adjuvant treatment, whose modalities do not meet with consensus, reduces this risk. LEVEL OF EVIDENCE: Retrospective series, level IV.

Bone density and functional results after femoral revision with a cementless press-fit stem.

INTRODUCTION: The influence of radiographic bone density changes in the area surrounding a total hip arthroplasty (THA) revision with a cementless press-fit stem is unknown, notably in terms of functional results. We have therefore conducted a study aiming to (1) propose a radiographic method to assess bone density, (2) measure the functional effects of reduced bone density, and (3) determine the factors contributing to these modifications. HYPOTHESIS: A reduction in radiographic bone density has a negative influence on the functional result after revision using a cementless press-fit stem. MATERIAL AND METHODS: We retrospectively assessed 150 THA revisions at a mean follow-up of 6.3 ± 3.2 years (range, 2-15 years). The clinical assessment was based on the Harris Hip Score. Bone density modifications were measured radiographically and the method was evaluated. The change in bone density was classified into two groups: (1) bone density not reduced or < 2 Gruen zones (118 cases [79%]); (2) bone density reduced ≥ 2 zones (32 cases [21%]). The variables showing a potential influence were the Cortical Index (CI), the type of primary stability with the press-fit system, and the femoral implant length. RESULTS: Inter- and intraobserver reliability of radiographic bone density measurement was evaluated as moderate or good (Kappa, 0.58; 0.60 and 0.67, respectively). For the Harris Hip Score at follow-up, there was a borderline statistical relation between stages 1 and 2: for the 118 stage 1 patients, this score was 83.62 ± 11.54 (range, 27-99) versus 78.34 ± 15.98 (range, 62-91) for stage 2 patients (P = 0.09). A CI ≤ 0.44 showed mediocre bone quality contributing to decreased bone density (P < 0.02). On the other hand, there was no statistically significant relation with the type of primary fixation (P = 0.34) or the length of the implant (P = 0.23). CONCLUSIONS: A cementless revision femoral stem can induce a reduction in bone density with possible functional effects. The negative role played by bone scarcity on the functional score is confirmed, and even though the difference is not statistically significant, we suggest using a short stem when this is possible.

Critical analysis of olecranon fracture management by pre-contoured locking plates.

BACKGROUND: Fractures of the proximal ulna are rare and usually managed surgically. Strong fixation of the harware is essential to obtain good outcomes. We report our experience with pre-contoured locking plate fixation of complex olecranon fractures and present a critical appraisal of the outcomes. HYPOTHESIS: Pre-contoured locking plates provide good outcomes, but their clinical tolerance may be limited in some instances. MATERIALS AND METHODS: From September 2009 to December 2011, 28 patients were managed using a pre-contoured locking compression plate (LCP(®)). Among them, 6 were excluded because of missing data, which left 22 patients (11 males and 11 females) with a mean age of 55.7 years, including 12 who were employed. The fracture was on the dominant side in 11 patients. According to the Mayo Clinic classification, 15 fractures were type II and 7 type III. In addition to the ulnar fracture, a radial head fracture was present in 9 patients and a coronoid process fracture in 5 patients. Functional recovery was assessed using the Broberg-Morrey score and Mayo Elbow Performance Score (MEPS). Radiographs were obtained to evaluate the quality of fracture reduction and fracture healing, as well as to look for ossifications and osteoarthritis. RESULTS: Mean follow-up was 20 months. Flexion was 131°, extension loss was 9.5°, pronation was 79°, and supination was 80.5°. The mean Broberg-Morrey score was 96.7 and the mean MEPS score 96.6. Fracture healing occurred in all patients, within a mean of 10.6 weeks. Evidence of early osteoarthritis was found in 6 patients, ossifications in 3 patients, and synostosis in 1 patient. An infection was successfully treated with lavage and antibiotic therapy in 1 patient. The fixation hardware was removed in 6 patients. No prognostic factors were identified. DISCUSSION-CONCLUSION: Our hypothesis was confirmed. The outcomes are encouraging and comparable to those reported in the literature. The critical issue is the limited clinical tolerance of the plate with a high rate of posterior impingement requiring plate removal (27%). Rigorous technique is essential during plate implantation. LEVEL OF EVIDENCE: Level IV, retrospective study.

Revision of primary total hip arthroplasty for peri-prosthetic fracture: A prospective epidemiological study of 249 consecutive cases in France.

BACKGROUND: Revision total hip arthroplasty (reTHA) for peri-prosthetic fracture (PPF) is increasingly performed but still ranks fourth among reasons for reTHA in registries. In France, no specific registry is available and the frequency of PPF among reasons for THA revision is therefore unknown. Here, our objectives were to determine the relative frequency of PPF as a reason for reTHA, to identify patient-related and primary-THA-related factors associated with reTHA for PPF, to describe reTHA modalities for PPF, and to determine the morbidity and mortality associated with reTHA for PPF. HYPOTHESIS: PPF is the second most common reason for reTHA, after loosening. METHODS: Consecutive reTHA procedures performed in 30 French centres over a 2-year period were collected prospectively. Repeat revisions and revisions of hemi-arthroplasties were excluded. The epidemiological, clinical, and surgical data needed to answer the questions of the study were collected. RESULTS: PPF was the second leading reason for reTHA (249/2107, 11.8%). Vancouver type B2 fractures were the most common (n=127 [51.5%]). Compared to patients who underwent reTHA for reasons other than PPF, those with reTHA for PPF were older at primary THA (67.9 years versus 57.7 years) and more often had intra-operative complications (16.9% versus 11.6%); furthermore, the primary THA was more often cementless (62.7% versus 42.7%) with a dual-mobility cup (20.6% versus 11.1%). At reTHA, the patients with PPF were older (77.6 years versus 69.2 years), had worst medical condition (mean ASA score, 2.4 versus 2.1) and less physically active (mean Devane score, 2.1 versus 2.4). The patients with reTHA for PPF had a shorter time to revision (9.8 years versus 11.4 years), a longer operative time (144 minutes versus 128 minutes), and more frequent use of the posterior approach (77% versus 67%) with a cementless dual-mobility cup (78% versus 60%) and a cementless revision femoral stem (72% versus 50%). Morbidity and mortality rates were high (5.9% operative complication rate and 12% of surgical complications with 4.8% mortality within the first 3 months) however, these results were similar to those in the rest of the cohort. DISCUSSION AND CONCLUSION: PPF is the second most common reason for reTHA, a result that is at variance with data in national registries. LEVEL OF EVIDENCE: Level IV, prospective observational cohort study.

Distal targeting device for long Gamma nail(®). Monocentric observational study.

INTRODUCTION: Intramedullary nail distal locking screws make it possible to control length and rotation but include an increased risk of radiation exposure. A distal targeting device was recently developed for long Gamma(®) nails (Stryker(®)). The aim of this practical observational study was to evaluate the reliability of this system. Our hypothesis was that the targeting device would be systematically used without conversion or complications. MATERIALS AND METHODS: All of the long Gamma(®) nails implanted between November 2011 and October 2012 were recorded: 91 nails (59W/32M, mean age 73.5years old) for 68 traumatic fractures, 14 preventive nailings and nine pathological fractures. A junior surgeon performed the procedure in 45 cases and a senior in 46 cases. The number of times the device was used, the difficulties and complications encountered, the duration of fluoroscopy and the dose of radiation were noted. Risk factors were looked for. RESULTS: The targeting device was used 79 times (the surgeon chose not to use it 11 times, and it was not available in one case). There was a measurement error in one case, therefore 78 nails could be evaluated. Three wrong positions of the distal locking screw occurred. No statistically significant risk factors were identified. Distal locking screw corresponded to 18% of the entire procedure at a radiation dose of 7.44% (this was higher with titanium nails and pathological fractures). Total fluoroscopy time was longer with junior than with senior surgeons but the dose and duration for distal locking were not different. DISCUSSION: The hypothesis was not confirmed. The device was not systematically used and the risk of complications was not null. No risk factors were identified. The distal locking screw is a difficult step but the use of the targeting device can limit the dose of radiation. This device is effective and allows young surgeons to perform distal locking without increasing the dose of radiation compared to senior surgeons. LEVEL OF EVIDENCE: Level IV, cohort study, observational prospective follow-up.

Minimally invasive fixation of type B and C interprosthetic femoral fractures.

INTRODUCTION: Interprosthetic femoral fractures are rare and raise unresolved treatment issues such as the length of the fixation material that best prevents secondary fractures. Awareness of the advantages of locked-plate fixation via a minimally invasive approach remains limited, despite the potential of this method for improving success rates. HYPOTHESIS: Femur-spanning (from the trochanters to the condyles) locked-plate fixation via a minimally invasive approach provides high healing rates with no secondary fractures. MATERIALS AND METHODS: From January 2004 to May 2011, all eight patients seen for interprosthetic fractures were treated with minimally invasive locked-plate fixation. Mean time since hip arthroplasty was 47.5 months and mean time since knee arthroplasty was 72.6 months. There were 12 standard primary prostheses and four revision prostheses; 11 prostheses were cemented and a single prosthesis showed femoral loosening. Classification about the hip prostheses was Vancouver B in one patient and Vancouver C in seven patients; about the knee prosthesis, the fracture was SoFCOT B in three patients and SOFCOT C in five patients, and a single fracture was SoFCOT D. Minimally invasive locking-plate fixation was performed in all eight patients, with installation on a traction table in seven patients. RESULTS: Healing was obtained in all eight patients, after a mean of 14 weeks (range, 12-16 weeks). One patient had malalignment with more than 5° of varus. There were no general or infectious complications. One patient died, 32 months after surgery. The mean Parker-Palmer mobility score decreased from 6.2 pre-operatively to 2.5 at last follow-up. Early construct failure after 3 weeks in one patient required surgical revision. There was no change in implant fixation at last follow-up. No secondary fractures were recorded. DISCUSSION: In patients with type B or C interprosthetic fractures, femur-spanning fixation not only avoids complications related to altered bone stock and presence of prosthetic material, but also decreases the risk of secondary fractures by eliminating stress riser zones. The minimally invasive option enhances healing by preserving the fracture haematoma. Thus, healing was obtained consistently in our patients, with no secondary fractures, although the construct failed in one patient. LEVEL OF EVIDENCE: Level IV.

Distal femur fractures. Surgical techniques and a review of the literature.

Fractures of the distal femur are rare and severe. The estimated frequency is 0.4% with an epidemiology that varies: there is a classic bimodal distribution, with a frequency peak for men in their 30s and a peak for elderly women; however, at present it is found predominantly in women and in the elderly with more than 50% of patients who are over 65. The most common mechanism is an indirect trauma on a bent knee, and more rarely direct trauma by crushing. The anatomy of the distal femur explains the three major types of fracture. Because of the anatomy of the distal femur, only surgical treatment is indicated to stabilize the fracture. A non-surgical treatment is a rare option. The aim of this report was to provide an update on the existing surgical solutions for the management of these fractures and describe details of the surgical technique applicable to these injuries. Recent radiological, clinical and biomechanical data published in the literature are reported to compare different surgical options.

Treatment of distal humerus fractures with LCP DHP™ locking plates in patients older than 65 years.

INTRODUCTION: Fractures of the distal humerus are often complex and therefore challenging to treat. In elderly patients with decreased bone strength due to osteoporosis, strong fixation is crucial to allow resuming early motion that guarantees a good functional outcome as well as minimising mechanical complications. Locked implants meet these requirements. Here, we report outcomes in a uniform series of patients older than 65 years with distal humerus fractures managed with LCP DHP(®) (Synthès) fixation. Our objective was to evaluate the efficacy and limitations of this technique. HYPOTHESIS: LCP DHP provides strong fixation of osteoporotic bone and leads to good clinical and radiological outcomes. MATERIALS AND METHODS: We retrospectively studied 46 consecutive patients (2004-2010) with a mean age of 80 years including 15 with extra-articular and 31 with articular distal humerus fractures. At presentation, 11 complications were noted in nine patients (compound fractures and trauma-related nerve injuries). The transolecranon approach was used in 31 patients. Mean duration of immobilisation was 2.7 weeks in 33 patients. RESULTS: Forty-three patients were re-evaluated after a mean follow-up of 25 months (range, 10-64 months); two patients died and one was lost to follow-up. Flexion was 127° and loss of extension was 23°, producing an average range of motion of 104°. Functional recovery was highly satisfactory with a Mayo Clinic Performance Score of 87 (70-100) and 95% of good and very good results. Postoperative complications consisted of infection (n=3), metaphyseal non-union (n=2), ulnar nerve injury (n=6), transient radial nerve palsy (n=1), and peri-articular ossification (n=4). Compound fracture and worse AO fracture type were associated with worse functional outcomes. DISCUSSION: Despite the high complication rate, functional recovery was similar to that reported in previous case series, including after arthroplasty. Furthermore, the rate of mechanical complications was lower. Thus, our working hypothesis was confirmed. LEVEL OF EVIDENCE: Level IV retrospective non-comparative study.

Complex fractures of the distal humerus in the elderly: is primary total elbow arthroplasty a valid treatment alternative? A series of 20 cases.

INTRODUCTION: Distal humerus fractures are fairly rare. But as our population ages, these fractures become more complex and the choice of treatment more delicate. Poor bone quality results in many technical problems and the fixation hardware stability remains at risk. The goal of this study was to evaluate the functional recovery and morbidity of complex distal humerus fractures in elderly patients when treated with elbow prosthesis. HYPOTHESIS: Good functional recovery can be achieved with a total joint replacement. PATIENTS AND METHODS: This series consisted of 20 patients (18 women and two men) having an average age of 80years (range 65-93, median 80). Based on the AO classification, there were two Type A2 fractures, two Type B fractures, 15 Type C fractures and one fracture that could not be classified because of previous rheumatoid disease history at this elbow. Two fractures were open. In two cases, the olecranon was also fractured. Treatment consisted of the implantation of a Coonrad-Morrey, hinge-type total elbow prosthesis (Zimmer(®), Warsaw, IN, USA). The Mayo Clinic surgical approach was used 17 times and the transolecranon approach was used three times. Primary arthroplasty was performed in 19 cases and the surgery was performed after six weeks of conservative treatment (diagnostic delay) in one case. Unrestricted motion was allowed after surgery, but a maximum of 0.5kg could be carried during the first 3months; this was subsequently increased to 2.5kg. RESULTS: Fifteen of the 20 patients were available for reevaluation with an average follow-up of 3.6years (range 1.7-5.5, median 3.4). Four patients had died and one was lost to follow-up. The average range of motion was 97° (range 60-130°), comprising an average flexion of 130° (range 110-140°) and average loss of extension of 33° (range 0-80°). Pronation and supination were normal. The average Mayo Elbow Performance Score (MEPS) was 83 (range 60-100, median 80). X-rays revealed seven cases of radiolucent lines, with two being progressive. There was no visible wear of the polyethylene bushings at the hinge. Six patients had moderate periarticular heterotopic ossification. The two cases of olecranon osteotomy and one case of olecranon fracture had healed. There were no surgical site infections but two cases of ulnar compression, one of which required neurolysis. There was one case of humeral component loosening after 6years, but the implant was not changed. DISCUSSION: The clinical range of motion results were comparable to published data. The functional scores were slightly lower, mainly because of the pain factor. The initial results were encouraging and consistent with published data as long as the indications were well-chosen. Based on this retrospective study, total elbow arthroplasty can be a valid alternative in the surgeon's treatment armamentarium for complex distal humerus fractures in elderly patients who have moderate functional demands. Our results support our hypothesis, since we found good functional recovery without associated morbidity. LEVEL OF EVIDENCE: Level IV retrospective study without comparator.

Early surgical site infections in adult spinal trauma: a prospective, multicentre study of infection rates and risk factors.

INTRODUCTION: Spine surgery is known to have a high risk of surgical site infection (SSI). Multiple studies have looked into the risk factors and incidence of SSI during elective surgery, but only two retrospective studies have specifically evaluated SSI during surgery following spine trauma. MATERIALS AND METHODS: This work was based on a prospective cohort study that included all the patients operated on for spinal trauma at 13 French hospitals over a three-month period. The main endpoint was the occurrence of a SSI during the three-month period. Patients with multiple trauma or open fractures were excluded from the study. RESULTS: Of the 169 patients re-examined after a minimum of three months, six had had an acute SSI (3.55%). The following factors were significantly related to a SSI: age, ASA score, diabetes, procedure duration, delay elapsed between accident and procedure, number of levels fused, bleeding and prolonged presence of urinary catheter. DISCUSSION: Our results were consistent with the published infection rates of 2 to 10%. The risk factors identified have all been described in previous studies on elective spine surgery. LEVEL OF EVIDENCE: Level IV, prospective cohort study.

Impact of a surgical site infection (SSI) surveillance program in orthopedics and traumatology.

UNLABELLED: Surveillance of surgical site infections (SSI) is a priority. One of the fundamental principles for the surveillance of SSI is based on receiving effective field feedback (retro-information). The aim of this study was to report the results of a program of SSI surveillance and validate the hypothesis that there is a correlation between creating a SSI surveillance program and a reduction in SSI. MATERIALS AND METHODS: The protocol was based on the weekly collection of surveillance data obtained directly from the different information systems in different departments. A delay of 3 months was established before extraction and analysis of data and information from the surgical teams. The NNIS index (National Nosocomial Infections Surveillance System) developed by the American surveillance system and the reduction of length of hospital stay index Journées d'hospitalisation évitées (JHE). RESULTS: Since the end of 2009, 7156 surgical procedures were evaluated (rate of inclusion 97.3%), and 84 SSI were registered with a significant decrease over time from 1.86% to 0.66%. A total of 418 days of hospitalization have been saved since the beginning of the surveillance system. DISCUSSION: Our surveillance system has three strong points: follow-up is continuous, specifically adapted to orthopedic traumatology and nearly exhaustive. The extraction of data directly from hospital information systems effectively improves the collection of data on surgical procedures. The implementation of a SSI surveillance protocol reduces SSI. LEVEL OF EVIDENCE: Level III. Prospective study.

Early surgical site infection in adult appendicular skeleton trauma surgery: a multicenter prospective series.

INTRODUCTION: Surgical site infections (SSI) studies rely on an imprecise and debatable definition. The term "wound healing problems" (WHP), not necessarily septic, is also frequently cited. This study had the objectives of determining the frequency of early SSIs in traumatology, these terms eventual correlation, and the factors influencing onset. PATIENTS AND METHODS: A multicenter prospective observational study was conducted in 12 centers. The exclusion criteria were open lesions as well as multiple injuries and multiple fractures (more than two fractures treated surgically). All patients were followed for the first three postoperative months until there was clinical certainty of healing and absence of infection. The presence of any WHP or SSI required a minimum follow-up of 1 year. WHP and SSI risk factors were determined using logistical regression adjusted on the centers. RESULTS: Out of 1617 cases, 103 were complicated by a WHP and 22 by a SSI. The SSIs were mainly secondary to Staphylococcus infections. The factors predisposing the patients to WHP and SSI (p≤0.05) were age; the NNIS, ASA, and Parker scores; alcoholism; antiaggregant use; and the locoregional aspect at the time of injury. The 522 subcutaneous osteosyntheses "near the skin" resulted in 58 WHPs (11%) and 14 SSIs (2.7%); 13 of the 58 WHPs (22%) resulted in one SSI. Out of 707 deep osteosyntheses, 24 (3.4%) presented a WHP and seven (1%) a SSI; Four SSIs originated from a WHP. The 352 fractures of the trochanter were complicated by a WHP in 15 cases (5.5%) and a SSI in one case (0.4%) after interlocked nailing and two WHPs and two SSIs (2.5%) after screw and plate fixation. Of the 388 first-line arthroplasties, only the prostheses implanted for a proximal femur fracture presented complications: 21 WHPs (6%) and one SSI (0.02%). Of the 103 WHPs of the entire series, 18 became SSIs. In absence of WHP, the SSI rate was 0.2%, whereas the probability of a WHP evolving toward a SSI was 100 times higher. The only factor significantly associated with a WHP becoming a SSI was osteosynthesis material exposure. DISCUSSION: This prospective study can be criticized on several points: the deliberately limited inclusion criteria, the short follow-up, and the possible subjectivity of the data collection. The SSI rates reported are for the most part in agreement with the literature. This study is innovative in traumatology given the large number of patients and the notion of WHP that was preferred over superficial infection. It demonstrates the relations between WHP and SSI, in particular for osteosyntheses near the skin. LEVEL OF EVIDENCE: Level III.

Advantage and limitations of a minimally-invasive approach and early weight bearing in the treatment of tibial shaft fractures with locking plates.

OBJECTIVES: Intramedullary nailing is a common method of treating tibial shaft fractures. However, precise control of reduction at the proximal and distal quarters is difficult to achieve. The purpose of this study was to assess the results of plating using locking screws and the feasibility of a minimally-invasive approach. PATIENTS/PARTICIPANTS: All patients with tibial shaft fracture treated by means of locking plates from January 2004 to October 2006. Thirty-two fractures were treated in 32 patients with a mean age of 43.8 years. INTERVENTION: Internal fixation with a locking plate and screw construct, using a minimally-invasive or standard approach. MAIN OUTCOME MEASUREMENTS: Surgical approach, time to weight bearing, complications and their type, time to bone union, alignment in the frontal and sagittal planes on anteroposterior and lateral radiographs. RESULTS: The minimally-invasive approach was performed in 28 cases and immediate full weight bearing allowed in 25 cases. At a mean follow-up of 27 months, two patients had died and two patients were lost to follow-up. The mean time to bone union was 9.1 weeks. Four cases had a complicated course: one infection, one compartment syndrome, one hardware breakage and one pseudarthrosis. Six cases ended up with valgus malunion exceeding 5° in the frontal plane, already present at the time of surgery. CONCLUSION: Where a minimally-invasive approach can be performed, immediate pain-free weight bearing can be allowed without further displacement at follow-up. The observed rate of malunion underlines the need for adequate reduction and shows that the rationale for success does not solely depend on the plate anatomic design but also on the skills of the operating surgeon. SETTING: Level I university regional hospital Cohort study.