Gamma nail in the treatment of closed trochanteric fractures. Results and indications of 121 cases.

The Gamma Nail is the latest advance in the treatment of trochanteric fractures based on intramedullary nailing principles during closed procedures. Its design is based on Küntscher's Y-nail and locking intramedullary (IM) nails. This paper reports the results from the first-ever series of 121 patients operated between 1988 and 1990. They were followed until bone union was achieved. The mean patient age was 75 years. Most patients were in poor general health and had unstable fractures. Anatomical preoperative reduction was achieved in 72% of cases. Fixation was good in 66% of cases and acceptable in 27% of cases. Intra-operative complications consisted of nine fractures without consequences. Of the treated patients, 83.4% resumed weight-bearing during the first week. There was one case of deep infection that resolved with treatment. The mortality rate was 12.3% at three months. We noted 7 alunions in varus, 3 in valgus, 2 in external rotation and 1 in internal rotation. There were no cases of non-union. In six cases, the screw had cut out of the femoral head. The drawbacks associated with surgical treatment methods for trochanteric fractures also apply to the Gamma nail. Nevertheless, one of its primary advantages is the possibility of using a closed procedure. When compared to Ender nailing, knee pain is absent and weight-bearing can be achieved in all patients, no matter the fracture type.

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.

Influence of preoperative cognitive status on propofol requirement to maintain hypnosis in the elderly.

BACKGROUND: The loss of cholinergic neurones in the basal forebrain has been shown to correlate to the extent of cognitive dysfunction during ageing in humans and to the hypnotic potency of propofol in animal models. We examined how the preoperative cognitive status, as assessed by mini-mental state examination (MMSE), may interact with propofol consumption during anaesthesia in the elderly. METHODS: In a prospective study, we recruited 41 patients (65-99 yr) undergoing surgery for hip fracture. Femoral nerve block was performed for analgesia. Target-controlled infusion of propofol (Schnider's model) was adjusted to the bispectral index within the range 40-60. Multiple linear regression analysis determined whether age, BMI, gender, duration of anaesthesia, and preoperative MMSE score affected the propofol consumption (general linear model, Systat 8.0). RESULTS: BMI and MMSE score significantly affected the mean value of propofol consumption. A low MMSE score (below 19) was associated with an observed decrease in propofol requirement in patients >65 yr of age. No significant effect of age, gender, and duration of anaesthesia on the propofol consumption was observed. CONCLUSIONS: Propofol requirement to maintain hypnosis during general anaesthesia appears to decrease with deterioration in the cognitive status in the elderly. We suggest that a cognitive dysfunction linked to a cerebral cholinergic dysfunction may influence the brain sensitivity for propofol in aged patients.

[Imaging of traumatic injuries of the hip]. / Imagerie des traumatismes de la hanche.

Traumatic injuries of the hip, mostly fractures of the proximal femur, are in constant progression. Though morbidity has decreased due to improved surgical and anesthesiologic techniques and postsurgical rehabilitation, mortality from hip fractures remains significant. Radiographs of the hip remain helpful, but MDCT and MRI have become indispensable tools. Findings on imaging studies must be well characterized to ensure rapid and cost-effective management. Difficult or cases with imaging features that are difficult to interpret or misleading will be presented to avoid incorrect interpretations that could lead to inadequate management of patients.

Post-traumatic intracranial epidural Aspergillus fumigatus abscess.

We report an intracranial epidural abscess caused by Aspergillus fumigatus in an immunocompetent patient. Infection occurred in a 20-year-old man 2 months after a frontal craniotomy following trauma. The abscess was encapsulated by a thickened dura and although the fungus did not invade the brain, frontal bone was infected and the patient presented with a subcutaneous frontal cellulitis. Initial management combined surgical drainage, resection of necrotic bone and liposomal amphotericin B (1 mg kg-1 per day). After 3 weeks of antifungal treatment a second evaluation surgery was performed. A clinically and radiologically unsuspected new abscess was found and evacuated. Treatment was completed with instillation into the cavity of amphotericin B at a concentration of 5 mg ml-1 and prolonged oral itraconazole (400-600 mg day-1). Treatment was successful and the patient is free of infection after 3 years.

[Mechanical performance of non slotted small diameter nails of Gross and Kempf]. / Performances mécaniques des clous de tibia de Grosse et Kempf non fendus de faible diamètre.

The goal of this study was to evaluate the mechanical properties of closed section small diameter Grosse-Kempf tibia nails. This type of implant has been advocated for an unreamed nailing of open tibia fractures in order to avoid further damage of bone blood supply and an increased risk for compartment syndrome. Static and dynamic tests were performed on 9 and 10 mm nonslotted Grosse-Kempf (G-K) and Russel-Taylor (R-T) nails. Results were compared with the properties of a 11 mm slotted G-K nail, considered as the reference nail. Axial loading tests were realized on nailed cadaver tibiae after resection of a midshaft bone segment. 3 points bending tests have shown a mean diminution of the elastic limit of 50 per cent, and a 25 per cent decrease of the bending rigidity for the closed section nails, as compared with the slotted reference nail. The rigidity in torsion was on the other hand 10 times higher with the nonslotted nails, which is a direct consequence of the elimination of the slot. Axial loading tests performed on isolated implants have given comparable results for all types of nails, including the reference nail. Nailed tibiae axially loaded demonstrated a stable bone-implant interface for loads up to 200 daN, with a mean displacement of 2 mm for a 50 daN load, whatever the type of the nail. Bending tests achieved on locking screws have indicated that G-K screws are twice as rigid as R-T screws.(ABSTRACT TRUNCATED AT 250 WORDS)

[Interlocking nail according to Seidel in recent diaphyseal fractures of the humerus. Review of 41 cases of 48 fractures]. / L'enclouage verrouillé selon Seidel des fractures diaphysaires humérales récentes. 41 cas revus sur 48 fractures.

The Seidel's humeral interlocking nail is used in our department since december 1986. We report about the 48 first cases, 41 of them have been reviewed with a mean time follow up of 14 months. The indications were humeral mid-shaft fractures with associated lesions (20 cases), failures of non operative treatment (10 cases) and compound fractures (7 cases). Primary radialis nerve lesions has to be explored before nailing. In 41 cases we used a static procedure; post-operative immobilisation average time: were 13 days. Consolidation occurred in all cases within an average time of 10.5 weeks. Post-operative complications consisted in 1 case of infection healed after removal of the nail, and 1 case of secondary displacement after dynamic nailing with secondary radio-circumflex paralysis. The results were appreciated concording to the criteria of Stewart and Hundlay. We noted 64 per cent excellent and good results for fractures of the upper third, 80 per cent for fractures of the middle third and 85 per cent for the distal third of the diaphysis. All transverse fractures had a very good result but also the transverse and spiral fractures with third fragment which represent very unstable fractures especially at the upper third. The closed interlocking nailing of the humeral fractures according to Seidel represents a reliable and stable fixation method. Consolidation occurs in all cases whatever the type or the level of fracture.

Open adult femoral shaft fracture treated by early intramedullary nailing.

In two hospitals, 115 consecutive open femoral shaft fractures were treated by meticulous wound excision and early locked (97) or unlocked (18) intramedullary nailing. All the fractures united; union was delayed in four, three of which required bone grafting. The average range of knee flexion at follow-up was 134 degrees (60 to 148). Five patients had a final range of less than 120 degrees, but three of these improved after manipulation under general anaesthesia. Three patients developed staphylococcal infections and required further surgical treatment. All eventually healed.

[Gamma nail in the treatment of closed trochanteric fractures. Results and indications apropos of 121 cases]. / Le clou gamma dans le traitement à foyer fermé des fractures trochantériennes. Résultats et indications à propos d'une série de 121 cas.

The Gamma Nail, developed at the Centre for traumatology and orthopaedics of Strasbourg, is the latest advance in the treatment of trochanteric fractures, based on the intra-medullary principle and on the closed procedure. It was inspired both by the Y nail of Küntscher and by the interloking nail. This is the study of the results of a first series of 121 cases treated between 1988 and 1990 and followed until consolidation. The mean age was 75 years, mostly patients in poor general condition, unstable fracture types were predominant. The preoperative reduction was anatomic in 72 per cent and the quality of osteosynthesis was good in 66 per cent, acceptable in 27 per cent; 83.4 per cent of the patients resumed full weight bearing during the first week. Only one case of deep infection occurred, treated by Gentamicyn beeds without removal of the nail. The mortality rate was 12.3 per cent at three months. We note 7 malunions in varus > 10 degrees, 3 in valgus > 10 degrees, 2 in external rotation > 10 degrees and 1 internal rotation > 10 degrees. In six cases, there was a cut out of the femoral head by the screw (in two cases the screws were too short, in four cases they were in a bad position). The same criticism against all surgical methods of treatment of trochanteric fractures can be done against the Gamma Nail. Nevertheless, it keeps the advantages of a closed procedure and, in comparison to the Ender nail, the absence of knee pain and the systematic weight bearing whatever the fracture type.

[Screw fixation of fractures of the odontoid process]. / Ostéosynthèse par vissage des fractures de l'apophyse odontoïde.

In the year 1981, J. Böhler completed for the first time a screw fixation for unstable fractures of the odontoid process of the axis. This surgical technique preserves the anatomy and the physiology of the articulation between the atlas and the axis, as a guarantee for a good functional recovery. It is not a very difficult technique when performed by a trained surgeon with a very good X-ray image intensification for the per-operative control. We have treated 32 unstable fractures of the odontoid process without any neurological complication per- or post-operatively. We had a follow-up on only 29 cases. In 19 cases the fracture healed in leading to a good bone union, complete mobility and no residual pain. Seven patients complained of residual pain or a limitation in cervical movement, because of the association with other cervical fractures, an age superior of 70 years, or a major initial instability. In 2 cases the authors noted a non-union and a secondary displacement because of technical faults at the beginning of their experience. These good results determined the authors to prefer the direct screw fixation for the unstable fractures of the odontoid process, to the posterior arthrodesis which leads to functional limitations.

[Interlocking central medullary nailing of recent femoral and tibial fractures. Statistical study apropos of 835 cases]. / L'enclouage centro-médullaire avec verrouillage des fractures récentes du fémur et du tibia. Etude statistique à propos de 835 cas.

Kuntscher's conventional closed intra-medullary nailing represents a good procedure in the treatment of diaphyseal fractures of the femur and the tibia but had a very restricted area (the midshaft) of indications. Thanks to the interlocking technic which consists in the fixation of the nail to the bone by means of transfixing screws either in a static or in a dynamic procedure, the method can be extended to fractures localised between both epiphysis of the long bones. After a first period between 1974 and 1983 of development of the method summarized in a first statistic, a second study was performed between 1984 and 1989 in the Center of Traumatology of Strasbourg with 837 cases of fresh fractures of the femur (385) and the tibia (397) treated by locked intra-medullary nailing. In two third of the cases the procedure was static and in one third it was dynamic. Full weight bearing was allowed in a mean period of 60 days. On the femur (371 closed and 65 open fractures), we had noted 8 infections out of which 2 deep infections (0.45%), 5 non unions, 25 moderate malunions in varus and 18 in valgus. On the tibia (267 closed and 132 open fractures) we had observed 15 deep infections (3.7%) out of which 9 (2.2%) after open fractures, 15 non unions (3.7%), 22 compartment syndroms, 6 mal unions in varus and 54 malunions in valgus greater than 5 degrees out of which 15 greater than 10 degrees.