[Femoral neck fractures in patients over 50 years old]. / Les fractures du col du fémur après 50 ans.

INTRODUCTION: Despite many papers and instructional course lectures, therapeutic guidelines are not clearly defined about treatment of femoral neck fractures. The aim of this multicentric French symposium was to prospectively study the results of current therapeutic options in order to propose scientifically proven options. MATERIAL AND METHODS: Three prospective studies were carried out in order to answer to these questions: (1) is it possible with anatomical reduction and stable fixation to lower the non union and osteonecrosis rate? (2) is functional treatment of Garden 1 fractures successful in more than 65 years patients? (3) what criteria are useful to choose the kind of arthroplasty for more than 65 years patients? RESULTS: For the 64 patients between 50 and 65 years old included in the first study, 44 ORIF and 17 prostheses were performed. No open reduction was performed in this series despite a 34% malreduction rate. The risk for displacement after functional treatment of Garden 1 fractures is 31%. For patients over 65 years old, almost fractures are treated in this series by an arthroplasty. The one-year mortality rate after displaced femoral neck fracture was 17%. Functional results were better in total hip prosthesis group than in bipolar or unipolar group. Non cemented stems were not safer than cemented ones in frail patients. DISCUSSION AND CONCLUSIONS: For young patients, ORIF should be the treatment of choice: the initial displacement and its effects on the femoral head vascularisation, the quality of reduction and fixation are the two most significant factors for good outcome. For Garden 1, fractures in patients 65 years old or more, it is proposed to performed an internal fixation despite in two thirds of the cases, it should be unnecessary because non identification of predictive factors of failure. For patients over 65 years old, the type of arthroplasty to perform in displaced fractures is to be chosen according to the preoperative mobility and comorbidities. Because of acetabular erosion with long-term follow-up, it is clearly indicated to perform total hip replacement for patients with life expectancy of 10 years or more. For frail patients, unipolar arthroplasty is the best option. The place for bipolar or uncemented implants is not yet well-defined and more prospective trials are needed. In this multicentric study, results appear quite different in terms of mortality, or functional status. These differences seem to be related to technical choice, geriatric care, nutritional consideration or surgical organisation, all factors that may be of major importance for prognostic.

[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.

[The chief clinician of universities--resident of hospitals: his pedagogic impact]. / Le chef de clinique des universités-assistant des hôpitaux: son rôle et son impact pédagogique.

When a resident is named "Chef de Clinique des Universités-Assistant des Hôpitaux" he has reached the top rung of specialist's training in France. In addition to his role within the hospital ("Assistant des Hôpitaux"), a role learned during the residentship, the title of "Chef de Clinique des Universités" means that he has a teaching role which is acquired intuitively on the basis of experience rather than actually being taught. The resident is given no special training before, as a young "Chef", he is called upon to teach medical students, residents, nurses, physical therapists or even patients under the authority of a professor. Teaching is done in various distinct locations (University and hospital: bedside, operating theatre, emergency room, consultations) which further complicates the new situation. The aim of this work was to retrospectively examine the teaching role of the "Chef de Clinique" based on personal experience both as a resident and as "Chef". Personal experience is given as an introduction to each paragraph.

[Histological study of the porous coating of the uncemented acetabulum. Apropos of 11 implants removed at autopsy]. / Etude histologique du revêtement poreux de cotyles non cimentés. A propos de 11 implants retirés lors d'autopsie.

Tissue ingrowth in the porous coating of 11 cementless acetabular components has been studied histologically. These cups were retrieved at autopsy from 8 patients who had undergone a primary total hip arthroplasty. Seven cups had a mean implantation period of 5.1 years, the other 4 had been in place for less than one year. This component was made of commercially pure (cp) titanium, with a porous surface of cp titanium fiber metal. The initial fixation of the cup was achieved by screws. The tissues of the porous coating were studied into 1 mm fields at four levels, and were categorized either as bone, marrow, cartilage or fibrous tissue. The fraction of void space within the porous coating occupied by bone was measured by backscattered scanning electron microscopy. The percentage of 1 mm fields with bony tissue was 20.9% and the fraction of void space occupied by bone was 12%. No regional significant difference was found. The number of fields with bone increased from the interface between the porous coating and the substrate of the cup to the interface between the outer surface of the porous coating and the host bone. All the screw threads were covered with lamellar bone. In the longest term cases, fine metallic and polyethylene debris were observed and their amount increased with time. This study showed that, despite the important variability in bone ingrowth, these cementless cups were able to give entire satisfaction to the patients.

A quantitative study of bone and soft tissues in cementless porous-coated acetabular components retrieved at autopsy.

The authors examined 11 cementless acetabular components of one design retrieved at autopsy and made observations concerning tissue ingrowth and local tissue reaction, radiographic-histologic correlation, and the distribution of particulate wear debris. The cups were hemispherical in design with a commercially pure titanium fiber-metal porous coating. All of the prostheses were implanted with screws. The implants were in place for an average of 41 months (range, 5 weeks to 75 months). Ten of the cups had bone ingrowth, with the average volume fraction being 12.1 +/- 8.2%. There were no differences in the amount of bone ingrowth when the component was partitioned into nine anatomic regions. However, there was more bone adjacent to screw holes through which screws were inserted compared with empty screw holes. As the number of radiolucent zones increased on the clinical radiographs less bone ingrowth was observed histologically. The amount of metal debris in holes with screws and holes without screws was similar. In the longest term cases, polyethylene debris was noted within empty screw holes, but no granulomatous reactions or osteolytic processes were observed.