Philippe Adam

Pitfalls and complications with locking plate for proximal humerus fracture

PURPOSE The aim of this study was to identify specific complications of locking plate fixation of proximal humerus fractures. PATIENTS AND METHODS Seventy-three adult patients with a displaced 3- (24%) or 4-part (76%) fracture of the proximal humerus were treated over a period of 2 years under the supervision of a trauma surgeon. Fourty-four patients came back for a clinical and radiographic examinations at least 18 months after the trauma; the others were evaluated at 6 weeks and 3 and 6 months. RESULTS Out of the 73 patients (64.4% females, mean age of 65), 11 patients needed a second surgery and 18 were lost for follow-up after 6 months. Mean final constant score was 62.3 points. The incidence of secondary displacement was 8.2%. Nonunion rate was 5.5%, affecting the constant score (P = .018). 16.4% of the patients developed a partial necrosis of the humeral head at the latest follow-up, which influenced on the constant score (P = .029). Quality of the reduction of the greater tuberosity influenced final results (P = .037). Screw cutout rate was 13.7%, with an influence to the constant score (P = .001). A too high plate positioning influenced the constant score (P = .002). CONCLUSION Locked screw-plates provide more secure fixation of fractures, especially in weak bone. Complications rate remains high. Two complications are to be distinguished: 1) technical complications in plate positioning, length of the screws or secondary screw cutout strongly influence the final clinical result; and 2) specific complications related to this technology such as pseudarthrosis or plate fracture.

Minimally invasive surgery with locking plate for periprosthetic femoral fractures: technical note

PurposePeriprosthetic fractures of the femur are increasing due to the increase of arthroplasties and the aging population. They concern a population that is often elderly and with important comorbidities that complicate managing this already complex pathology. Usual complications of classic osteosynthesis are numerous, including infections and nonunions and the need for delayed weight bearing after surgery.Methods—resultsThe development of locking plates has allowed complication avoidance. When used in minimally invasive surgery, they combine the biological advantages of closed-wound surgery to the mechanical advantages of locking plates, which have better stability in fragile bones. We propose a technical update on handling such fractures by using locking plates under minimally invasive surgery.Discussion—conclusionIn our experience, under certain guidelines, this allows for immediate post-operative full weight bearing, which is beneficial to these often elderly patients.

Supra-patellar swelling and knee instability

DiagnosisIntra-articular lipoma causing patellofemoral instability andsubluxation.DiscussionIntra-articular knee masses are rare, with an incidence ofonly 33 out of 2,200 knee arthroscopies described in theliterature [1]. Lipomas are common benign tumours, but anintra-articular localisation is exceptional. Two types oflipomatous entities can be found: solitary lipoma andlipoma arborescens. They differ in pathogenesis and grossappearance, although their microscopic features are similar.Lipoma arborescens, the more frequent of the two intra-articular tumours, is usually considered to be a secondarylesion, occurring in the context of either inflammatory ordegenerative joint disease, or after trauma [2–4]. Microscop-ically, lipoma arborescens is manifested as a diffuse hyper-plasic villous proliferation of the synovium in response tochronic irritation. Magnetic resonance imaging (MRI) exam-ination is pathognomonic, showing multinodular fatty tissueinfiltrating and protruding into the joint. The tissue showscontrast enhancement, and an effusion is often present.Solitary intra-articular lipoma is not associated with pre-existing pathology, and no causative factors can be identi-fied. Macroscopically, it is a soft yellow solitary mass, roundor ovoid in shape, uni- or poly-lobed, and finely encapsu-lated. It is usually small and often pediculated. It is thoughtto develop from the fat of the suprapatellar or retropatellarregions. On MRI the fatty signal shows increased intensity inT1 sequences and decreased intensity in all the sequenceswith saturation of the fat. There is no enhancement afterinjection of contrast medium.Seventeen cases of intra-articular lipoma of thekneewerefound in the international literature. This lesion is a rarecause of pain or internal articular dysfunction of the knee.Clinical presentation may vary from a simple palpable massto a more complex association of pain, swelling and internalderangement. There is a relationship between anatomicallocalisation and clinical presentation. Tumours of the supra-patellar region usually present as a simple palpable mass.However, localisation within Hoffa’s fat pad or between thefemur and tibia may have more varied manifestations, withpain, reduced range of motion and joint locking.Our case was an unusually large tumoral mass with apeculiar presentation. To our knowledge, it is the firstexample of patellofemoral instability with patellar sublux-ation due to intra-articular lipoma, although there has beenone previously reported case with perturbation of patellofe-moral tracking [5].

Rapid chondrolysis of the medial knee compartment after arthroscopic meniscal resection: a case report

BackgroundRapidly destructive osteoarthritis of the hip and rapid chondrolysis of the lateral compartment of the knee or the shoulder are rare, but have been previously described in the medical literature. To the best of our knowledge, no case of medial femorotibial compartment chondrolysis after arthroscopy has yet been described. We therefore submit the first case report.Case presentationA 64-year-old white European man presented with right knee pain due to a medial meniscal tear with no other abnormality found on examination or imaging. An arthroscopic partial medial meniscectomy was performed and early evolution was favorable with no signs of infection. He developed knee pain 2 months later. X-rays showed a thinning of the medial compartment which was confirmed by computed tomography arthrogram. There was no articular effusion, mobility was conserved (0/0/125°), there was no laxity, and pain was localized to the medial femorotibial compartment, with no meniscal signs. There was a 8° varus deviation (versus 3° for his uninjured left knee). His blood work was normal. As there were no signs of infection, no aspiration was performed. Viscosupplementation was offered but refused by the patient. He is now waiting for a partial knee replacement.ConclusionsTo the best of our knowledge, this is the first description of such a case. Rapid chondrolysis has been described in the hip, shoulder, and the lateral compartment of the knee. Infiltration of bupivacaine and lateral meniscectomy are the most frequently sited offending procedures. Concerning the medial compartment, cases of avascular necrosis have been reported after meniscectomy or use of radiofrequency devices. This case underlines the necessity of a thorough physical examination and complete radiological work up before any surgery. It must also drive us to use caution regarding meniscectomy, especially in patients over 60 years of age, and reminds us that patients must be informed of this potential complication.