Patrick Cronier

Tibiotalocalcaneal Fusion Using the Hindfoot Arthrodesis Nail A Multicenter Study

Background: Tibiotalocalcaneal arthrodesis is a salvage option for severe ankle and hindfoot deformities, arthritis of the ankle and subtalar joints, avascular necrosis of the talus, failed total ankle arthroplasty, and Charcot arthropathy. This multicenter study reports clinical experience with the hindfoot arthrodesis nail (HAN) in the treatment of patients with severe ankle and foot abnormalities. Methods: Seven participating clinics from Europe and North America recruited 38 patients who underwent ankle/subtalar arthrodesis using retrograde nailing with the HAN. Information was collected regarding technical details, complications, and functional and quality of life outcomes (Short Form-36 [SF-36], American Academy of Orthopaedic Surgeons—Foot and Ankle Outcomes [AAOS-FAO], and numeric rating scale [NRS] for pain) after an average of 2 years of follow-up. Results: The rate of superficial wound infection was 2.4%. No deep soft tissue or bone infections were reported. The overall union rate was 84%. At the time of follow-up, low pain levels were reported, with a mean NRS of 2.2; the mean AAOS-FAO score was 38; and the SF-36 mean physical and mental health component scores were 41.2 and 52.5, respectively. All 13 patients who were unable to work prior to surgery were able to fully return to work. Conclusions: The HAN offered a safe and reliable salvage option for tibiotalocalcaneal arthrodesis in patients with severe ankle and hindfoot disease. It achieved acceptable functional outcome and low complication rates despite the challenging patient cohort. A considerable socioeconomic benefit appeared to result based on the high proportion of patients who were able to return to work postoperatively. Level of Evidence: Level IV, retrospective case series.

A prospective study of a new locking plate for proximal humeral fracture

Displaced and unstable extra-articular fractures of the proximal humerus are treated by operative reduction and fixation using various techniques such as fixed plates and intramedullary implants. This prospective study evaluates the clinical efficacy of a novel implant that is attached to the humeral head with fixed-angle locking screws. Between October 2002 and November 2005, 99 people (mean age 62.8 years) with proximal humeral fractures received treatment involving this plate in our department. The mean follow-up time was 17.8 months. Outcome was assessed with radiography, the Constant-Murley (C-M) shoulder evaluation and the Disabilities of the Arm, Shoulder and Hand (DASH) score. The mean C-M score was 64.95% and the mean DASH score was 30.1 points. Outcome was judged excellent in 51%, good in 19%, moderate in 19% and poor in 11% of cases.

Traitement des fractures récentes de la diaphyse humérale par enclouage centromédullaire verrouillé rétrograde: Une étude prospective de 58 cas

Resume Le traitement des fractures de la diaphyse humerale reste controverse. Parmi les moyens d’osteosynthese classiques, l’enclouage a foyer ferme a ete adapte a l’humerus assez tardivement dans sa forme anterograde. Le passage a la voie retrograde est recent et permet de preserver la coiffe des rotateurs. Cette etude rapporte les resultats de 58 fractures diaphysaires humerales de l’adulte traitee par enclouage retrograde entre janvier 2000 et decembre 2003. Ce travail concernait uniquement les fractures diaphysaires recentes sur os non pathologique de l’adulte. Ont ete inclus uniquement les traits de fractures situes entre l’insertion du grand pectoral et un point situe a 2 cm au dessus du sommet de la fossette olecrânienne. La serie comportait 58 patients avec 58 fractures humerales, fermees a l’exception de 4 qui presentaient une ouverture en regard du foyer (type I et II de Gustilo). Deux patients avaient une paralysie radiale preoperatoire qui n’a pas ete consideree comme une contre-indication a la methode. Les 2 paralysies ont d’ailleurs recupere dont une au prix d’une neurolyse de principe effectuee simultanement a l’enclouage. L’osteosynthese a ete realisee a foyer ferme sous controle de l’amplificateur de brillance par enclouage retrograde verrouille statique sur des patients installes en decubitus dorsal. A l’exception de 2 deces precoces sans rapport avec la methode, la consolidation a ete obtenue en moyenne en 15 semaines. Elle a ete obtenue per primam chez 53 patients. Dans 3 cas, une mise en compression secondaire a ete necessaire. Au dernier recul, les mobilites postoperatoires de l’epaule etaient normales chez 88 % des patients, et celle du coude normales dans 91 % des cas. Le score fonctionnel de Rommens etait bon dans 84 % des cas. Les complications comportaient 3 paralysies radiales postoperatoires regressives, 3 cas d’algodystrophie dont 2 ont regresse et 2 cas de fractures de la palette humerale qui ont necessite une reprise chirurgicale par osteosynthese. Les ablations de vis proximales ont ete pratiquees dans 6 cas en raison de douleurs ou de migration. Trois ablations de materiel ont ete realisees sans probleme. Il n’y a pas eu d’infection. Ce materiel implante par voie retrograde a facilite le traitement des fractures diaphysaires humerales en permettant une mobilisation immediate et en apportant les avantages du foyer ferme: pas d’infection, pas d’echec de consolidation obligeant a changer de methode. Les difficultes techniques residuelles concernent le verrouillage proximal et l’introduction du clou genee par sa forme bequillee.PURPOSE OF THE STUDY Appropriate treatment for humeral shaft fractures remains a debated issue. Among the classical osteosynthesis techniques proposed, closed nailing was adapted to the humerus rather late, using the anterograde method. Use of retrograde nailing, which spares the rotator cuff, is more recent. The purpose of this study was to report outcome in 58 humeral shaft fractures in adults treated using the universal humeral nail between January 2000 and December 2003. MATERIAL AND METHODS This work was limited to recent shaft fractures in adults with non-pathological bones. The fractures included were all situated between the insertion of the pectoralis major and a point situated 2 cm above the apex of the olecraneum fossa. The series included 58 patients with 58 humeral shaft fractures. All fractures were closed except four (Gustilo type I and II). Two patients presented preoperative radial paralysis which was not considered to be a contraindication for retrograde locking nailing. The paralysis recovered in both patients, after neurolysis performed during the nailing procedure in one. Osteosynthesis was performed without opening the fracture focus under fluoroscopic control using a static locking nail inserted retrograde in patients in the supine position. RESULTS There were two early deaths unrelated to the method. Healing was obtained in the surviving patients within fifteen weeks on average. Bone healing was primary in 53 patients and after secondary compression in three. At last follow-up, shoulder motion was normal in 88% of patients and elbow motion in 91%. The Rommens functional score was good in 84%. Complications included three cases of spontaneously regressive postoperative radial paralysis, three cases of reflex dystrophy including two which regressed, and two cases of humeral palette fracture requiring surgical osteosynthesis. The proximal screws were removed in six patients because of pain or migration. To date, implants have been removed in three patients without problem. There were no infections. CONCLUSION Retrograde insertion of this nail facilitates treatment of humeral shaft fractures by allowing immediate joint motion and the advantages of closed reduction: no infection, no late bone healing requiring conversion to another method of fixation. The residual technical problems concern proximal nailing and nail introduction.

Internal fixation of complex fractures of the tarsal navicular with locking plates. A report of 10 cases.

INTRODUCTION Tarsal navicular fractures are rare and treatment of comminuted fractures is especially difficult. Since 2007, the authors have had access to 3D reconstruction from CT scan images and specific locking plates, and they decided to evaluate whether these elements improved management of these severe cases. MATERIALS AND METHODS Between 2007 and 2011, 10 comminuted tarsal navicular fractures were treated in a prospective study. All of the fractures were evaluated by 3D reconstruction from CT scan images, with suppression of the posterior tarsal bones. The surgical approach was chosen according to the type of lesion. Reduction was achieved with a mini-distractor when necessary, and stabilized by AO locking plate fixation (Synthes™). Patient follow-up included a clinical and radiological evaluation (Maryland Foot score, AOFAS score). Eight patients underwent postoperative CT scan. RESULTS All patients were followed up after a mean 20.5 months. Union was obtained in all patients and arthrodesis was not necessary in any of them. The mean Maryland Foot score was 92.8/100, and the AOFAS score 90.6/100. One patient with an associated comminuted calcaneal fracture had minimal sequella from a compartment syndrome of the foot. DISCUSSION The authors did not find any series in the literature that reported evaluating tarsal navicular fractures by 3D reconstruction from CT scan images. The images obtained after suppression of the posterior tarsal bones systematically showed a lateral plantar fragment attached to the plantar calcaneonavicular ligament, which is essential for stability, and which helped determine the reduction technique. Locking plate fixation of these fractures has never been reported. CONCLUSION Comminuted fractures of the tarsal navicular were successfully treated with specific imaging techniques in particular 3D reconstructions of CT scan images to choose the surgical approach and the reduction technique. Locking plate fixation of the navicular seems to be a satisfactory solution for the treatment of these particularly difficult fractures. LEVEL OF EVIDENCE Level IV.

Isolated interfragmentary compression for nonunion of humeral shaft fractures initially treated by nailing: A preliminary report of seven cases.

INTRODUCTION Plating with bone grafting is considered the gold standard treatment for nonunion of humeral shaft fractures. However, this complex procedure involves multiple risks. The aim of this study is to evaluate an alternative treatment using isolated axial interfragmentary compression for the dynamisation of humeral shaft nonunion after retrograde locked nailing. MATERIALS AND METHODS Between January 2000 and May 2009, 124 humeral shaft fractures were treated in our trauma department with retrograde locked nailing using the unreamed humeral nail (UHN(®), Synthes, Paoli, PA, USA). Nonunion occurred in seven patients (5.6%) - five females and two males, mean age 44 years (range: 17-73 years). The nonunion was treated by applying isolated secondary interfragmentary compression. Mean follow-up was 43 months (range: 8-74 months). The Rommens score and the disabilities of the arm, shoulder and hand (DASH) score were used to evaluate the global functioning of the upper limb. RESULTS The compression procedure was successful in all seven cases. In each case, the union occurred without any complications in 3-5 months. The mean DASH score was 25/100 (range: 8.3-60.8/100). The Rommens score was judged excellent for five of the seven patients but two were rated moderate. One of these suffered from complex regional pain syndrome type II since the fracture, and another developed a stiff shoulder 6 months after trauma. CONCLUSION Isolated secondary interfragmentary compression appears to be a simple and successful procedure in cases of humeral nonunion.

Ostéosynthèse par plaque antérieure verrouillée des fractures complexes de l'extrémité distale du radius : Contribution au maintien de la longueur radiale

PURPOSE OF THE STUDY Maintaining radial length, likely to be the main challenge in the treatment of complex distal radius fractures, is necessary for complete grip-strength and pro-supination range recovery. In spite of frequent secondary displacements, bridging external-fixation has remained the reference method, either isolated or in association with additional percutaneous pins or volar plating. Also, there seems to be a relation between algodystrophy and the duration of traction applied on the radio-carpal joint. Fixed-angle volar plating offers the advantage of maintaining the reduction until fracture healing, without bridging the joint. MATERIAL AND METHODS In a prospective study, forty-three consecutive fractures of the distal radius with a positivated ulnar variance were treated with open reduction and fixed-angle volar plating. Results were assessed with special attention to the radial length and angulation obtained and maintained throughout treatment, based on repeated measurements of the ulnar variance and radial angulation in the first six months postoperatively. RESULTS The correction of the ulnar variance was maintained until complete recovery, independently of initial metaphyseal comminution, and of the amount of radial length gained at reduction. Only 3 patients lost more than 1 mm of radial length after reduction. The posterior tilt of the distal radial epiphysis was incompletely reduced in 13 cases, whereas reduction was partially lost in 6 elderly osteoporotic female patients. There was 8 articular malunions, all of them less than 2 mm. Secondary displacements were found to be related to a deficient locking technique. Eight patients developed an algodystropy. The risk factors for algodystrophy were articular malunion, associated posterior pining, and associated lesions of the ipsilateral upper limb. CONCLUSION Provided that the locking technique was correct, this type of fixation appeared efficient in maintaining the radial length in complex fractures of the distal radius. The main challenge remains the reduction of displaced articular fractures. Based on these results, it is not possible to conclude that this method is superior to external fixation.Resume Dans le traitement des fractures distales du radius a forte impaction metaphysaire, le maintien de la longueur radiale favorise la restauration de la force de prehension, et de la prono-supination du poignet. Les methodes conventionnelles, fondees sur la fixation externe radio-carpienne, avec ou sans osteosynthese interne, sont grevees d’un taux de syndromes algoneurodystrophiques lies a l’importance et a la duree de la traction exercee sur la capsule articulaire. L’utilisation de plaques verrouillees anterieures est susceptible de permettre la restauration et le maintien de la longueur radiale sans pontage articulaire. Une serie de 43 fractures du radius distal traitees par plaque verrouillee palmaire ont ete suivies jusqu’a consolidation. Toutes les fractures presentaient une comminution metaphysaire avec index radio-ulnaire positif. Le maintien de la longueur radiale, juge sur l’evolution de l’index radio-ulnaire pendant et apres reduction est apparu effectif meme en cas de comminution metaphysaire circonferentielle. La qualite de reduction articulaire a ete discutable avec huit cals vicieux, tous inferieurs a 2 mm. La bascule posterieure a ete insuffisamment reduite dans 13 cas et s’est aggravee dans 6 cas. Huit patients ont developpe une algodystrophie. La superiorite de cette methode par rapport au fixateur externe reste a demontrer par une etude comparative randomisee.

An original internal fixation technique by tension band wiring with steel wire in fractures of the coronoid process.

Fractures of the coronoid process, which is a key element in anterior elbow joint stability, represent 14% of proximal ulnar fractures. Optimal treatment should stabilize all fractures associated with elbow instability. Different techniques have been described: suture repair, screws, plates… We propose a series of 5 patients who were treated with an original, easy, tension band wiring fixation technique using steel wire with easy hardware removal.

Clinical and radiological outcomes of a cohort of 9 patients with anatomical fractures of the cuboid treated by locking plate fixation

INTRODUCTION Cuboid fractures are very rare. Hence, their treatment has not been standardized. Advances in imaging techniques, particularly three-dimensional computed tomography (3D CT), and the introduction of cuboid-specific plates has improved the care of these injuries. The aim of this study was to determine the radiological and clinical outcomes of anatomical reconstruction of comminuted cuboid fractures with a locking plate. HYPOTHESIS Fixation of comminuted cuboid fractures with a cuboid-specific locking plate leads to stable anatomical reduction and good functional outcomes. MATERIAL AND METHODS This was a retrospective study of 9 consecutive cases of comminuted cuboid fracture treated at a single hospital between January 2009 and December 2015. A 3D CT scan was performed preoperatively with subtraction of the posterior tarsal bone to allow the articular facets to be viewed and analyzed. Fracture fixation was done with a Locking Cuboid Plate (DePuy Synthes™). Associated lesions in the foot were treated during the same procedure. The patients were reviewed by an independent observer who performed a clinical examination, and determined the AOFAS and Maryland Foot Score. The success of the reconstruction was determined by comparing the parameters on weight-bearing X-rays views between the fixed and non-operated cuboid. RESULTS The mean follow-up was 4.1 years (range 1-6). The Maryland Foot Score was 93.1 [86-100] and the AOFAS was 91.9 [82-100]. The reconstruction was anatomical and long lasting in all 9 cases. There was no foot misalignment in the frontal plane, based on the radiographs (hindfoot axis 5.5° [0-9]). The mean Djian-Annonier angle was 123.9° [108-130]. CONCLUSION Cuboid fractures can be treated effectively through appropriate imaging and with a cuboid-specific locking plate as evidenced by very good midterm clinical and radiological outcomes in this study. LEVEL OF EVIDENCE IV Retrospective study.

Percutaneous reduction of proximal radius fracture in adults. A 12-case series

Fractures of the head or neck of the radius account for 5% of elbow fractures in adults. Treatment varies between authors. We report a retrospective series of 12 cases of percutaneous reduction of Mason II radial head fracture, without internal fixation. All fractures consolidated, without secondary displacement. There were no postoperative complications. Mean ranges of motion were 136° flexion-extension and 175° pronation-supination. Mean QuickDASH score was 11. Results in the present series were at least comparable to those for other techniques, validating percutaneous treatment as a solution for radial head fracture. TYPE OF STUDY Case series. LEVEL OF EVIDENCE IV.