F. Bonnomet

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

INTRODUCTIONnDistal 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.nnnHYPOTHESISnGood functional recovery can be achieved with a total joint replacement.nnnPATIENTS AND METHODSnThis series consisted of 20xa0patients (18 women and two men) having an average age of 80years (range 65-93, median 80). Based on the AO classification, there were two Typexa0A2 fractures, two Typexa0B fractures, 15 Typexa0C 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.nnnRESULTSnFifteen of the 20xa0patients 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.nnnDISCUSSIONnThe 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 surgeons 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.nnnLEVEL OF EVIDENCEnLevel IV retrospective study without comparator.

Interprosthetic femoral fractures: analysis of 14 cases. Proposal for an additional grade in the Vancouver and SoFCOT classifications.

INTRODUCTIONnInterprosthetic fracture is a rare but serious entity, impairing consolidation and stability due to adverse mechanical conditions related to bone fragility and implant volume.nnnOBJECTIVEnThe present study highlights the difficulties involved in managing such fractures, details treatment options and reports findings leading to a proposed additional grade in the comparable Vancouver (hip) and French Orthopedic and Traumatologic Surgery Society (Société française de chirurgie orthopédique et traumatologique: SoFCOT) (knee) classification systems.nnnPATIENTS AND METHODSnA multicenter retrospective series included 14 interprosthetic femoral fractures: eight type double C (typeC for both hip and knee), five type C for hip and B for knee, and one type double B (type B for both hip and knee) on the Vancouver and SoFCOT classifications. Fracture occurred on standard (n=15) or revision (n =13) implants. Six cases involved a femoral shaft encumbered by a total knee replacement (TKR) femoral extension stem and eight cases TKR without femoral long stem, assimilable to type C fracture.nnnRESULTSnNone of the six fractures proximal to a constrained TKR with stem-achieved union by primary intention, whereas seven of the eight type-C fractures did so. Finally, 12 cases showed favorable evolution, with three secondary total femur replacements (TFR) and one death at 6 months without bony union or revision and one patient waiting for TFR.nnnDISCUSSIONnTo describe the status of the intermediate femur and its medullary canal encumbrance, we propose adding a category D to the SoFCOT and Vancouver classifications, corresponding to interprosthetic fracture on TKR with diaphyseal extension stem. Interprosthetic fracture internal fixation should begin with long devices bridging the two prostheses. When the implant is loose, it may be replaced; in case of diaphyseal extension, however, the residual femur between the two extensions should be protected against peak stress by a plate extending upward and downward. In case of limited bone stock, due to osteolysis or initial femoral medullary canal compromise, especially if one or both implants are loose, TFR may be indicated as consolidation, is jeopardized by the uncertain mechanical situation.

Technical difficulties in hardware removal in titanium compression plates with locking screws.

UNLABELLEDnWith the advent of locking screws fixation devices, came new problems when removing internal fixation hardware. The objective of this study was to evaluate these problems and their possible solutions. The first problem was screws jamming on the plate, secondary to either initial poor screwing technique (with inadequate placement of the targeting device) or use of excessive force (when screwing in the screws without using the torque-controlling screwdriver). Treatment consists of destroying the screw heads using tungsten drills. The screw bodies can then be extracted using a trephine drill. The second problem involves destruction of the recess of the screw head. It can be secondary to overly forceful screw insertion or risky screw extraction. This can be treated using a specific conical left-turn screwdriver, assuming that the screw/plate thread is still intact. Finally, the screw recess can be filled. The plate itself may be a source of problems when being extracted because the screw holes left free also have been filled. Lever arm maneuvers to raise the fibrous bridges and substantial traction along the axis can be useful. These problems are more frequent with minimally invasive surgery. The consequences of this fixation types hardware removal surgery are multiple: lengthened operative time, risk of secondary maximally invasive surgery, presence of metallic shavings residues in cases of screw head destruction, and the risk of iterative fracture secondary to trephine drill use. Prevention is thus essential. It is based on rigorous technique in placing the targeting device, drilling, and inserting screws, the systematic use of the torque-controlling screwdriver, and the verification of proper screw position. The locking compression plate (LCP) material is highly effective but its removal should not become challenging.nnnLEVEL OF EVIDENCEnLevel V.

Early prediction of femoral head avascular necrosis following neck fracture.

Femoral neck fracture puts at risk functional prognosis in young patients and can be life-threatening in the elderly. The present study reviews methods of femoral head vascularity assessment following neck fracture, to address the following issues: what is the risk of osteonecrosis? And what, in the light of this risk, is the best-adapted treatment to avoid iterative surgery? Femoral head vascularity depends on retinacular vessels and especially the lateral epiphyseal artery, which contributes from 70 to 80% of the femoral head vascular supply. Fracture causes vascular lesions, which are in turn the prime cause of necrosis. Other factors combine with this: hematoma tamponade effect, reduced joint space and increased pressure due to lower extremity positioning in extension/internal rotation/abduction during surgery. Head deformity is not due to direct cell death but to the repair process originating from the surrounding living bone. In post-traumatic necrosis, proliferation rapidly invades the head, with significant osteogenesis. Pathologic fractures occur at the boundary between the new and dead bone. Many techniques have been reported to help assess residual hemodynamics and risk of necrosis. Some are invasive: superselective angiography, intra-osseous oxygen pressure measurement, or Doppler-laser hemodynamic measurement; others involve imaging: scintigraphy, conventionnal or dynamic MRI. The future seems to lie with dynamic MRI, which allows a new classification of femoral neck fractures, based on a non-invasive assessment of femoral head vascularity.

Periprosthetic femoral fractures: The minimally invasive fixation option

UNLABELLEDnIncreasingly frequent periprosthetic fractures are affecting the elderly; this patients group often suffers from significant co-morbidities that make it particularly difficult to manage these already complex injuries. The classic pitfalls of conservative treatment are many, including infections, pseudarthrosis and the growing necessity of different postoperative supports. We present an internal fixation technique by minimally invasive surgery to manage periprosthetic fractures. The hardware used is a locking plate, with manufacturers recommendations usually allowing immediate weight bearing. This minimally invasive method provides optimal stability to the fixation, while avoiding the open approach shortcomings.nnnLEVEL OF EVIDENCEnIV: retrospective or historical series.

Minimally-invasive fixation of distal extra-articular femur fractures with locking plates: Limitations and failures

Minimally-invasive fixation using a locking plate and early motion is normal practice. However, technical errors and pitfalls are common. This surgery has a set of rules that encompass both the mechanics of the internal fixation system and the implantation itself. If these rules are not strictly followed, alignment defects and/or early failure of the fixation can occur. We analysed four cases of clinical failure that were encountered after minimally-invasive distal femoral extra-articular fixation with locking plates. The following rules must be followed with this technique: extra-articular fracture, minimally-invasive approach, long plate alternating between locking screw and empty hole (five holes on either side of fracture), bi-cortical screws, placement of locking screws near a complex fracture but away from a simple fracture. Osteoporotic bone, obesity that interferes with the instrumentation, articular fracture, horizontal fracture line and surgeon experience are all limitations of this minimally-invasive technique.

Minimally invasive locking screw plate fixation of non-articular proximal and distal tibia fractures.

Intramedullary nailing of proximal and distal quarter tibia fractures is known to be a challenging procedure due to the metaphyseal enlargement, the reduced contact between implant and cortex and fracture comminution. Therefore, some authors suggest preferring the use of plate internal fixation in the management of these challenging fractures. The purpose of this manuscript is to present and describe our technique of minimally invasive locking plate osteosynthesis in the treatment of extra-articular proximal and distal tibia fractures. Osteosynthesis was performed by means of a locking screw plate system which construct characteristics usually allow immediate weight-bearing and early functional mobilization. This minimally invasive surgical procedure advantageously combines the principles of closed fixation with construct stability.

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

INTRODUCTIONnSpine 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.nnnMATERIALS AND METHODSnThis 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.nnnRESULTSnOf 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.nnnDISCUSSIONnOur 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.nnnLEVEL OF EVIDENCEnLevel IV, prospective cohort study.

Minimally-invasive internal fixation of extra-articular distal femur fractures using a locking plate: Tricks of the trade

Fractures of the distal femur are rare and occur in two distinct population categories: young patients after high energy traumas and elderly patients who fall from their full height, and often carry severe co-morbidities making especially difficult to manage theses complex injuries. In elderly patients the potential complications are numerous including infection, non-union and frequent function deterioration. We present a technique of minimally invasive internal fixation of the distal extra-articular femur using a locking plate and present the tricks of the trade to obtain successful reduction and achieve union. The hardware used includes plate fixation with a large fragment locking screw. This minimally invasive surgery combines stability of the internal fixation device with the principles of closed surgery, allowing early mobilization and immediate weight bearing to warrant good functional recovery.

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

INTRODUCTIONnSurgical 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.nnnPATIENTS AND METHODSnA 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 1xa0year. WHP and SSI risk factors were determined using logistical regression adjusted on the centers.nnnRESULTSnOut 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.nnnDISCUSSIONnThis 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.nnnLEVEL OF EVIDENCEnLevel III.