[Grammont reversed prosthesis for acute complex fracture of the proximal humerus in an elderly population with 5 to 12 years follow-up]. / Arthroplastie inversée de Grammont pour fracture récente de l'humérus proximal chez la personne âgée avec un recul de 5 à 12 ans.

PURPOSE OF THE STUDY: Aim of this retrospective study was to analyze outcome in 23 cases of Delta III reverse ball-and-socket total shoulder prosthesis for acute complex fractures of the proximal humerus in an elderly population with poor bone quality. In such a population, this procedure could escape the difficulties of a reliable and efficient refixation of the tubercles. MATERIAL AND METHODS: From 1993 to 2000, 23 Delta III prostheses were implanted by a single operator for acute injury: 18 three-part and four-part fractures and 5 fracture-dislocations. The study population included two men and 21 women, mean age 75 years, 10 dominant sides. Surgery was performed under general anesthesia in the semi-sitting position via the anterolateral approach without osteotomy of the acromion, with 10-20 degrees retroversion of the humeral stem (except in one shoulder) and cement fixation in two. For five shoulders, the tubercles could be re-fixed. Postoperative physiotherapy was not possible in all patients. Outcome was assessed with the Constant score and with ap and lateral Lamy radiographs. RESULTS: Seven patients died so the series included sixteen cases for analysis. Complications were: reflex sympathetic dystrophy (n=2), postoperative Acinetobacter infection (n=1) requiring revision to clean and drain allowing preservation of the prosthesis, and early postoperative anterior dislocation (n=1) (10 degrees stem anteversion) with surgical revision to re-orient the stem. At mean follow-up of 86 months, the Constant score was 60 points (contralateral shoulder 83 points). Outcome, influenced in case of re-fixation of the tubercles, was good for pain (14.1), activity (13.3), strength (16.1), anterior elevation (6.5), and abduction (6.5), but very poor for external (1.1) and internal (2.4) rotations. The radiographs showed: aseptic glenoid loosening (n=1) at 12 years with surgical revision in 2005 with Constant score at 6 months follow-up of 48 points, inferior scapular notching (n=11) according the the Nérot classification (six stage 1, four stage 2, one stage 3, at 2, 4.3 and 5 years follow-up), inferior spurs (n=9) appearing at mean 2.5 years follow-up (stable after emergence without clinical impact), proximal humeral resorption (n=4) (medially for three at mean 8 year follow-up and one laterally at 10 years), and a humeral radiolucent line (n=1) at 5 years follow-up. DISCUSSION: For acute complex fractures of the proximal humerus in elderly subjects with poor bone quality, when an efficient and reliable re-fixation of the tubercles is difficult or impossible, reverse ball-and-socket shoulder prosthesis is a possible alternative providing good functional outcome except for rotations but with the risk of inferior scapular notching. Although not problematic in the mid term, these notches may contribute to glenoid loosening with bone loss in the long-term. Nevertheless, this procedure seems to improve the status of patients with such fractures.

[Two-pin L fixation of fractures of the fifth metacarpal neck]. / Embrochage en L, à deux broches, des fractures du col du cinquième métacarpien.

The authors present a retrospective review of 48 fractures of the fifth metacarpal neck in 48 patients, who underwent internal fixation using the two-pin L procedure. These fractures were treated between 1994 and 2000, in 5 female and 43 male patients with an average age of 27 years (range 14 to 58). Fighting and sporting accidents were the main etiology of injury. The indication for surgical treatment was volar displacement of over 30 degrees. The two-pin L procedure consists of stabilizing the fragments after reduction using one intra-medullary pin 2 mm in diameter introduced through a proximal approach, and a transverse distal pin 1.2 mm in diameter from the fifth toward the fourth metacarpal. All treatments were performed under nerve block. Early mobilization was authorized. Patients did not need any physiotherapy. Activity was resumed after three weeks, and the average time to the removal of pins was five weeks. In eight cases, it was necessary to remove the transverse distal pin around 21 days after surgery because of displacement of the pin causing pain under the skin. At three months follow-up, bone union was obtained in all cases, with a perfect range of motion of all finger joints, without any pain or reflex sympathetic dystrophy. The two-pin L procedure appears to be a reliable technique, which provided union in an anatomic position in all our cases, and also allowed early mobilization and provided good functional results.

[Vitamin C and prevention of reflex sympathetic dystrophy following surgical management of distal radius fractures]. / Vitamine C et prévention du syndrome douloureux régional complexe de type 1 après fracture du radius distal traitée chirurgicalement.

Reflex sympathetic dystrophy is a major complication following surgical treatment of fractures of the distal radius. Its pathogenesis is related to lipid peroxidation which damages vascular endothelial cells, increasing capillary permeability. Vitamin C is a natural antioxidant. The authors have made a comparative study of two groups of patients with isolated closed displaced fractures of the distal radius, which were reduced and stabilized by intrafocal pinning. Group 1 included 100 patients who were treated from 1995 until 1998 and who did not receive any vitamin C supplementation; group 2 included 95 patients who were treated from 1999 to 2002 and who received daily administration of one gram vitamin C orally during 45 days, starting on the day of fracture. The incidence of reflex sympathetic dystrophy was five time times lower in group 2 (2.1% versus 10%). This is in line with previous observations and lends credit to the value of vitamin C administration as a prophylactic measure to prevent the occurrence of reflex sympathetic dystrophy in patients who undergo surgical treatment of a displaced fracture of the distal radius.

[Chronic instability of the proximal tibio-fibular articulation: hemi-long biceps ligamentoplasty by the Weinert and Giachino technique. Apropos of 3 cases]. / Instabilité chronique de l'articulation tibio-fibulaire proximale: ligamento-plastie à l'hémi-long biceps selon Weinert et Giachino. A propos de 3 cas.

PURPOSE OF THE STUDY: Recurrent dislocations of the superior tibiofibular joint are rare. We report three cases of Weinert and Giachino ligament reconstruction. MATERIALS: From 1989 to 1994, two soccer players and one young girl (10 years old) presented recurrent dislocation of the superior TFJ. The mechanism was a direct trauma, and the type of dislocation was antero-lateral. These patients were free of tibial fracture, major ligament lesion of the knee, and neurologic symptoms (peroneal nerve injury). Pain was over the fibular head, mechanical and increased by jumping. A lateral "cracking" was present. Examination showed an antero-posterior mobility of the fibular head. X-ray showed horizontal proximal tibiofibular joint. M.R.I. eliminated a lateral meniscal pathology and collateral ligament injury. METHODS: The biceps tendon was split longitudinally for approximately seven centimeters. The posterior one half was transected proximally and mobilized. Secondly, the free end of the graft was passed posterior to anterior through a tibial tunnel. Thirdly, the tendon was sutured to the anterior tibial periosteum under tension with the fibular head reduced. RESULTS: Follow up at one year revealed that all the patients were active, free of dysfunction and laxity, with no further episodes of instability and no loss of ankle mobility. DISCUSSION: The diversity of treatments reported for this rare dislocation led us to believe that none proved its superiority. Resection of the proximal end of the fibula involves extensive dissection and creates a risk for the peroneal nerve vacuum and a lateral laxity. Arthrodesis of the superior tibiofibular joint without fibular osteotomy leads ankle pain, instability and a loss of ankle mobility. This procedure may also be complicated by screw loosening or breakage or by stress fracture of the fibula at the screw site. Arthrodesis of the superior tibiofibular joint with fibular osteotomy avoids these risks, but is possible for pain in the diaphyseal resection during the first 6 post operative months. Weinert and Giachino procedure, using a portion of the biceps tendon to reconstruct the superior tibiofibular ligament successfully stabilizes the superior tibiofibular joint, preserves all physiological function of the fibula and avoids resection or arthrodesis complications. CONCLUSION: Based on our experience with these three patients and on literature review, ligament reconstruction for recurrent dislocation of the superior tibiofibular joint gives stability and indolence, and avoids complications of resection and arthrodesis.

[Value of combined spinal and epidural anesthesia in the management of peroperative analgesia in prosthetic surgery of the lower limb. Prospective study of 68 cases]. / Intérêt de la péri-rachianesthésie combinée dans la prise en charge de la douleur péri-opératoire pour la chirurgie prothétique du membre inférieur. Etude prospective a propos de 60 cas.

PURPOSE OF THE STUDY: Efficient peri-operative analgesia is more comfortable, allows earlier mobilisation and better functional results for lower limb arthroplasties. We report our 60 cases prospective study of combined spinal and epidural anesthesia, and expose interests of this technique to control peri-operative pain. MATERIALS: From 1994 to 1995, 60 patients ASA class 1 were operated: 45 total hip replacement (THR), 15 total knee replacement (TKR). The average age was sixty five years (range thirty nine to eighty five years). Combined spinal and epidural anesthesia was performed in every case. METHODS: In lateral decubitus position, a translucent 25 Gauge needle was introduced in L2-L3 interspace. In a first time spinal anesthesia was made with 20 mg Bupivacaine. In a second time, a lumbar epidural catheter was inserted. All patients received an epidural post-operative analgesia with 4 mg Morphine once a day during two days and intravenous Paracetamol. Visual analogue scale (0 to 10) (VAS) were recorded after the third post operative hour and every twelve hours. During this period satisfaction mark was also recorded (1 to 3). RESULTS: We didn't observe any case of respiratory depression or infection with the epidural catheter. We observed 10 cases of pruritus (one needed to stop protocol) and 18 urinary retentions. Six uretral catheters were necessary; we had one case of pyelonephritis (escherichia coli). The first micturition was obtained 13.5 hours after the end of surgery. For the fifty nine remaining patients, visual analogue scale was always inferior or equal to 2/10 and the satisfaction mark to 1/3. DISCUSSION: Different techniques allow peri-operative analgesia, but a few are efficient during the first two days. Plexus nerve blocks are simple and reliable but post-operative anesthesia is short (inferior to 15 hours). Intravenous morphine controlled by patients themselves with programmed display needs expensive and sophisticated material. The principal risk is respiratory depression. Epidural morphine has a lower respiratory depression risk, but needs a heavier technique. The principal problems is higher incidence of urinary side effects. Epidural anesthesia might tend to show a greater efficacity with the best visual analogue scale and satisfaction mark. CONCLUSION: The results indicate that combined spinal and epidural anesthesia for the management of peri-operative pain provide an excellent pain control with a daily morphine injection. For lower limb arthroplasties, visual analogue scale is always inferior or equal to 2 and satisfaction mark equal to 1.

[Post-traumatic hemarthrosis of the knee in children. Role of arthroscopy]. / Hémarthroses post-traumatiques du genou chez l'enfant. Place de l'arthroscopie.

The results of a method in treating the post-traumatic hemarthrosis of the knee in children have been analyzed in a retrospective study covering 31 cases. In the presence of obvious initial lesions (11 cases) arthroscopy has had an only therapeutic function in three cases. In the absence of obvious initial lesions (20 cases) from afar, and without any prejudice on the final result, arthroscopy, if it has only been performed 13 times, has been therapeutic in seven cases. Once a routine way in surgery, in our experience it is justified in only half of the cases. Its diagnosis and therapeutic indications in children can, on our part, be limited and depend on a previous and very accurate examination followed by a careful and sustained treatment afterwards.

Grammont reversed prosthesis for acute complex fracture of the proximal humerus in an elderly population with 5 to 12 years follow-up.

PURPOSE OF THE STUDY: The aim of this retrospective study was to analyze outcome in 23 cases of Delta III reverse ball-and-socket total shoulder prosthesis implantation for acute complex fractures of the proximal humerus in an elderly population with poor bone quality. In this type of population, this procedure could respond to the difficulties of a reliable and efficient re-fixation of the tubercles. MATERIAL AND METHODS: From 1993 to 2000, 23 Delta III prostheses were implanted by a single operator for acute injury: 18 three-part and four-part fractures and five fracture-dislocations. The study population included two men and 21 women, mean age 75 years, ten on the dominant side. Surgery was performed under general anesthesia in the semi-sitting position via the anterolateral approach without osteotomy of the acromion, with 10-20° retroversion of the humeral stem (except in one shoulder) and cement fixation in two. For five shoulders, the tubercles were re-fixed. Postoperative physiotherapy was not possible in all patients. Outcome was assessed with the Constant score and with AP and lateral Lamy radiographs. RESULTS: Seven patients died so the series included 16 cases for analysis. Complications were: reflex sympathetic dystrophy (n=2), postoperative Acinetobacter infection (n=1) requiring revision to clean and drain allowing preservation of the prosthesis, and early postoperative anterior dislocation (n=1) (10° stem anteversion) with surgical revision to re-orient the stem. At a mean follow-up of 86 months, the Constant score was 60 points (contralateral shoulder, 83 points). Outcome, influenced in cases of re-fixation of the tubercles, was good for pain (14.1), activity (13.3), strength (16.1), anterior elevation (6.5), and abduction (6.5), but very poor for external (1.1) and internal (2.4) rotation. The radiographs showed aseptic glenoid loosening (n=1) at 12 years with surgical revision in 2005; the Constant score at 6 months follow-up was 48 points, inferior scapular notching (n=11) according the Nerot classification (six stage 1, four stage 2, one stage 3, at 2, 4.3, and 5 years follow-up), inferior spurs (n=9) appearing at a mean 2.5 years follow-up (stable after emergence without clinical impact), proximal humeral resorption (n=4) (medially for three at a mean 8 years follow-up and one laterally at 10 years), and a humeral radiolucent line (n=1) at 5 years follow-up. DISCUSSION: For acute complex fractures of the proximal humerus in elderly subjects with poor bone quality, when effective and reliable re-fixation of the tubercles is difficult or impossible, the reverse ball-and-socket shoulder prosthesis is a possible alternative providing good functional outcome except for rotations, but with the risk of inferior scapular notching. Although not problematic in the medium term, these notches may contribute to glenoid loosening with bone loss in the long term. Nevertheless, this procedure seems to improve the status of patients with such fractures.

Long term functional outcome following reverse shoulder arthroplasty in the elderly.

INTRODUCTION: The aim of this study is to analyze the long-term results and possible complications of the Grammont reverse shoulder prosthesis in the management of recent trauma in the elderly patient. PATIENTS AND METHODS: Two male and 33 female patients of mean age 75 years (range, 58 to 92), operated on for 24 fractures and eleven facture-dislocations, involving the right side in 11 cases and the left side in 24 cases, were included in a retrospective study and were clinically and radiographically evaluated at a mean follow-up ranging from 1 to 17 years. RESULTS: Eight complications occurred in eight patients (23%): two complex regional pain syndromes, four dislocations, one deep infection and one aseptic loosening of the metaglene. Six patients (17%) had to be reoperated on, without prosthetic replacement in four cases and with revision of their shoulder implant in two. The mean Constant score decreased from 55 to 53 between one postoperative year and last follow-up since patients complained of increased pain and strength loss. This score was 69% of that of the contralateral shoulder. The adjusted Constant score was 68%. Only 58% of the patients were "satisfied" or "very satisfied" with the treatment due to limited shoulder rotations thus preventing proper eating, dressing and body hygiene habits when injury involved the dominant side. Two cases of complete lucent lines surrounding the glenoid component were observed at four and eight postoperative years respectively, a stable inferior bony spur was noted in 14 cases at a mean follow-up of 2.5 years with no functional effects, 20 cases of scapular notching having occurred within two-year follow-up were identified, 10 of which associated with bone resorption and medial proximal humeral lucent lines at the bone-cement interface. The extent of scapular notching progressed with the length of follow-up. Forty-nine percent of the radiographic images were considered abnormal and appeared within seven-year follow-up in 60% of the cases. Clinical and radiographic data comparison revealed a decrease in the Constant score regarding pain, activity, strength and active elevation when scapular notching was associated with abnormal humeral radiographic images. DISCUSSION: Despite one single case of aseptic loosening of the metaglene at 12-year follow-up, the results of our series are clinically disappointing and radiographically worrying associated with a substantial rate of complications and reopperations. The long-term functional outcome is far from being identical to the pre-trauma clinical status with a potential evolution toward loss of autonomy when the dominant side is affected. New prosthetic design characteristics and surgical technique improvements should be implemented to improve shoulder adduction but also rotations while preventing the occurrence of scapular notching. In the light of these results, we cannot validate the concept of primary reverse shoulder arthroplasty in the management of recent trauma of the proximal humerus.

The reverse shoulder prosthesis in the treatment of fractures of the proximal humerus in the elderly.

We have previously described the short-term outcome of the use of reverse shoulder arthroplasty in the treatment of acute complex proximal humeral fractures in the elderly. We now report the clinical and radiological outcome of 36 fractures at a mean of 6.6 years (1 to 16). Previously, at a mean follow-up of 6 years (1 to 12) the mean Constant score was 58.5; this was reduced to 53 points with the further follow-up. A total of 23 patients (63%) had radiological evidence of loosening of the glenoid component. Nevertheless, only one patient had aseptic loosening of the baseplate at 12 years' follow-up. The reduction in the mean Constant score with longer follow-up and the further development of scapular notching is worrying. New developments in design, bearing surfaces and surgical technique, and further follow-up, will determine whether reverse shoulder arthroplasty has a place in the management of complex proximal humeral fractures in the elderly.

Delta III reverse shoulder arthroplasty: radiological outcome for acute complex fractures of the proximal humerus in elderly patients.

PURPOSE OF THE STUDY: Acute complex proximal humerus fractures in the elderly population, treated by internal fixation or hemiarthroplasty, give well reported radiological results. We investigated the radiological outcome of the reverse arthroplasty concept in this indication. MATERIAL AND METHODS: From 1993 to 2007, 41 Delta III prostheses were implanted following 32 three-part and four-part displaced fractures, and in nine fracture/dislocations; three fractured patients were males and 38 females; mean age at fracture time was 75 years. The results were evaluated on AP and Lamy lateral shoulder views. RESULTS: Since nine of these patients were deceased and two had moved, 30 cases were available at review, with a mean follow-up of 6.5 years (range, 1-14). The radiographs showed two thick radiolucent lines on the glenoid component with one aseptic loosening of the base plate at 12 years. Based on the Nérot classification, 17 cases of inferior scapular notching were, in total, observed. The mean time to onset was 2 years for the seven grade 1 notches (41%), 4 years for the five grade 2 notches (30%), 5 years for the three grade 3 notches (17%) and 6 years for the two grade 4 notches (12%). Fourteen inferior spurs (stable after emergence) were reported with a mean time to onset of 2.5 years (range, 1-6 years). One joint ossification occurred at 6 months and was stable at the 6-year follow-up review. The humeral component results comprised four cases of medial (5, 6, 7 and 10 years) proximal bone loss and two cases of bone-cement interface deterioration (medial radiolucent lines at two-third of the stem height at the 5-year follow-up). In these six cases, a notch was present above this area. In addition, one case of humeral septic loosening is reported at 2-year follow-up. CONCLUSION: For acute proximal humeral complex fractures in the elderly population, when refixation of the tuberosities on a classical orthopaedic devices appears compromised, the use of a Delta III reverse prosthesis is an attractive alternative; however, with a mean follow-up of 6.5 years, this prosthesis demonstrates unsatisfactory images in 70% of the cases. These flaws were noted on the glenoid component in 70% of the cases, appeared before 7 years in 86% and were progressive in 50% of the cases. However, only one revision was required for an aseptic loosening of the base plate at 12 years. New developments in designs and bearing surfaces and larger numbers analysis of long-term results will probably be needed to encourage extensive utilization of the reverse concept in this fracture indication. LEVEL OF EVIDENCE: Level IV. Therapeutic retrospective study.

Weinert and Giachino ligament arthroplasty for the surgical treatment of chronic superior tibiofibular joint instability.

Recurrent dislocations of the superior tibiofibular joint are rare. The majority of these patients are physically active, young adults. Different surgical techniques have been described for the management of this pathology: resection of the proximal aspect of the fibula, arthrodesis of the superior tibiofibular joint with or without fibular osteotomy. Because of the problems reported with these techniques, we opted for Weinert and Giachino ligament reconstruction. From 1989 to 1994, three patients were treated and reviewed in our practice: all, soccer players on the local team, 20, 23, and 25 years old, with superior tibiofibular pain and tumefaction, without neurological symptoms, but with anteroposterior mobility of the fibular head. The average duration of the symptoms before operation was 9 months, and the average follow-up was 15 months. At the follow-up, pain and anteroposterior mobility were gone. Soccer playing was resumed at 7 months without recurrence but with low frequency and stress. In our opinion, the Weinert and Giachino ligament reconstruction, using a portion of the biceps tendon to reconstruct the superior tibiofibular ligament, appears an effective approach to restore indolence and stability to the superior tibiofibular joint and to avoid complications of resection and arthrodesis.