Purpose of the study: Osteosynthesis material adapted to a mini-invasive approach certainly reduces surgical trauma. The purpose of this work was to establish the osteosynthesis equivalence for pertrochanteric fractures using a dynamic hip screw, inserted according to the conventional technique versus a mini-invasive screw system (MISS), in terms of healing without loss of reduction.

Material and methods: This was a prospective pilot study in a single centre. From May 2006 to April 2007, 78 patients (mean age 83 years, 70% women) were included (38 MISS, 40 DHS). There was one exclusion criteria: poor reduction on the orthopaedic table before incision. Radiographic and clinical follow-up for six months. The main outcome was the quality of the reduction and healing at three months.

Results: Eight patients were lost to follow-up and two had died at three months. The two groups were comparable regarding mean age, ASA, fracture type, operator experience, and centring of the head screw. In the MISS group, there was a 20% reduction in blood loss, a shorter incision (9 cm) and shorter operative time (16 min). The differences were not significant. The healing rate without loss of reduction at three months was the same in both groups: 82%. There were three revisions in the MISS group: one infection and two material disassemblies. This problem disappeared with the addition of a locking screw on the nail. There were no revisions for haematoma.

Discussion: There were several biases. The series was not really randomised because the type of material used depended on the availability of the instrument sets. The MISS implant evolved during the course of the study. The operators were more familiar with the DHS. Inclusion criteria were too restrictive. Multiple-injury patients with bleeding had a false impact on blood loss data. None of the differences were statistically significant. Revision for infection was not directly attributable to the material. Nail locking never failed after use of the locking screw.

Conclusion: The main outcome was validated: the healing rate without reduction at three months is equivalent with the two methods (82%). A multicentric study should be conducted to confirm that the mini-incision and the MISS reduces blood loss. It could be expected that this mini-invasive approach will become the rule for osteosynthesis of these fractures with a dynamic hip screw.

Purpose: The aim of this work was to assess retrospectively osteofixation and survival of a long custom-made femoral stem with complete hydroxyapatite coating and without locking for replacement of the femoral implant.

Material and methods: From 1990 to 1999, 89 stems were implanted for revision total hip arthroplasty. Seventy-five hips were reviewed at one to ten years (mean four years). Radiographic analysis searched for bone damage, osteofixation and implant migration. All measures were taken on the AP views postoperatively and at last follow-up.

Results: Revision was performed for aseptic loosening in 75%, for septic loosening in 12%, for fracture in 11% and for instability in 2%. Destruction was SOFCOT stage I in 36%, stage II in 44%, stage III in 17% and could not be assessed in 3%. The femorotomy approach was used in 60% and trochanterotomy in 32% and endofemoral assess in 8%. There were 18% intraoperative fractures, 4.8% postoperative infections and 2.4% dislocations. At last follow-up, the Postel Merle d’Aubigné score was 15.3 and the Harris Hip Score was 77.9. Thigh pain was present in 4%. Bone fixation was considered good in 48%, partial but better than 50% contact in 36% and could not be interpreted in 16%. Complete metaphyseal reconstruction was present in 8%. A piecemeal allograft was used in 89%. Between the postoperative and last follow-up films, 16% of the stems descended a mean 11 mm. Five percent of the stems were removed for infection and one (1.3%) for non-fixation. At five years, 95% of the stems was still in place and 80% at ten years, including removals for infection. All revisions for septic loosening had comparable clinical and radiological results in this series and did not develop secondary infection.

Discussion: These results demonstrate the usefulness of the uncemented stems for replacement compared with cemented stems which have a 10% revision rate at five years (SOFCOT 1999). The complete hydroxyapatite coating improves distal fixation of the stem in a healthy zone without compromising secondary proximal fixation and authorising spontaneous metaphyseal bone reconstructions. This may explain the low rate of painful thighs. Modularity and locking could improve the primary fixation and limit descent.

Purpose: Serratus anterior palsy is usually part of a Parsonnage and Turner syndrome. When occurring alone, it may be secondary to compression of the long thoracic nerve. The anatomic point of contact has been described at the level of the second rib. We report our experience with a musculofascial serratus anterior flap showing that the crossing point of the long thoracic nerve and the thoracic branch of the thoracodorsal artery, the serratus anterior fascia could also be a potential point of compression.

Material and method: We cared for two patients with complete and isolated palsy of the serratus anterior. In the first patient, the paralysis developed over one year and in the second had started three months before treatment. In both patients, the preoperative electromyogram showed an absence of serratus anterior activity. We therefore performed exoneurolysis of the long thoracic nerve in both cases. At surgery, the nerve was clearly compressed at the point where the long thoracic nerve crossed the thoracic branch of the thoracodorsal artery.

Results: The first patient recovered normal muscle activity one year after surgery. Complete recovery was achieved in the second patient at three months.

Discussion: These two cases would support the hypothesis that the long thoracic nerve can become compressed within the serratus anterior fascia. In all cases with serratus anterior palsy secondary to suspected mechanical compression, we propose exoneurolysis of the long thoracic nerve.