Purpose of the study: Misalignment after insufficient treatment of unstable fracture of the pelvis is often poorly tolerated, compromising quality-of-life due to limping, leg length discrepancy, posterior pain, uncomfortable sitting position and/or sexual disorders due to mechanical problems. Secondary surgical treatment can be proposed despite its invasive nature (generally three phase surgery). The purpose of this work was to present the technique and the results of standardized correction of pelvis misalignment using a two-phase procedure.

Material and methods: Eight consecutive patients (May 2002–May 2004) with sequelae of Tile C fractures were treated on average eight years after the initial trauma. A double-approach was used. The series included four men and four women, aged 18–43 years. The first posterior approach in the ventral supine position was used for osteotomy of the sacroiliac callus and systematic debridement by section of the sacroiliac ligaments. The secondary ilioinguinal approach was performed in the dorsal supine position to achieve osteotomy of the symphyseal callus, reduction of the iliac wing, and symphyseal synthesis using a sacroiliac plate anteriorly and percutaneous screws.

Results: The mean operative time was four hours 30 minutes. Blood loss required transfusion of 3.5 packed red cell units on average. Anatomic reduction was achieved in six cases, partial reduction in two. Despite one nosocomial infection and two partial popliteal external sciatic deficits, all patients wer satisfied with the operation at mean eight months follow-up. Bone healing was achieve din all cases.

Discussion: Standard two-phase surgery is possible for a wide range of cases. The anatomic result is reliable with good clinical outcome. The duration of the operation and blood loss are reduced compared with classical techniques.

Conclusion: Despite the advantage of this original operative strategy, surgery for correction of pelvis misalignment remains a difficult surgical procedure for selected and motivated patients informed of the operative risks.

Purpose of the study: Pelvic fractures disrupting the pelvic girdle often create a serious challenge for reduction and fixation. Type C fractures of the Tile classification provoke vertical instability. Percutaneous screw fixation under fluoroscopic control in patients positioned in dorsal decubitus enables an extension of early indications for fixation to patients with abdominal or thoracic injuries. The reduction is obtained by progressive transcondylar traction on an orthopedic table. The purpose of this study was to assess functional mid-term outcome and to analyze causes of failure.

Material and methods: From 1995 through 2003, we used the percutaneous sacroiliac screw fixation method for type C fractures in 25 patients; clinical assessment at 45 months mean follow-up was available for 22 patients. Six patients presented a bilateral lesion (C2), seven a vertical sacral fracture (C1-3), and nine sacroiliac disjunction (C1-2). One screw was inserted for ten patients, two screws for twelve. Complementary anterior osteosynthesis was performed for eight patients.

Results: The functional outcome was assessed with the Mageed score. The mean score was 801%. All patients presente satisfactory postoperative reduction (less than 10 mm residual vertical displacement). Early displacement was noted one day 10 in one patient who underwent a revision procedure. There were two late secondary displacements (one with mobilization and one with material fracture) which heal in a misaligned position. There were no iatrogenic complications (neurologic, vascular, infectious) and no cases of nonunion.

Discussion: The long-term functional results were directly related to the quality of the reduction, as previously demonstrated by Matta. In our series, the quality of the postoperative reduction was significantly correlated with time from trauma to surgery. This delay must be as short as possible (less than five days for Routt). The main complication was secondary displacement which was observed in this study among cases with a single posterior screw.

Conclusion: Percutaneous sacroiliac screw fixation provides good functional results and appears to be a safe technique if the initial reduction is satisfactory. Two posterior screws are needed to avoid secondary displacement.

Purpose: We analysed complications observed after 1771 implantations of single-compartment knee prostheses performed since 1974.

Material and methods: Sterilised all polyethylene Marmor implants were used from 1974 to 1984. Metal-backed tibial implants with or without cement and condyle resurfacing were added after 1984.

Results: Mean survival of the 207 Marmor cemented prostheses implanted from 1974 to 1984 was 93% at 12 years. There were nine significant complications: seven loosenings, three with infection, and two deteriorations of the other compartment. There were five minor complications: two instabilities, one patellar and one anterior laxity; two stiff joints; one meniscal lesion in the other compartment and one hamstring tendinitis. A non-adjustable cobalt-chromium metal backed insert was added to the polyethylene lining in 1984. For the 790 implants using this prosthesis, 48 had to be revised (6%) four to eight years after implantation for polyethylene wear due to an insufficient thickness for size 7.5 mm and gamma sterilisation.

These observations led us to use, since 1991, two new polyethylene inserts sterilised with ethylene oxide: an adjustable titanium metal-back support with cement in 329 cases and without cement in 171 with hydroxyapatite surfacing, and a modified Marmor with complete thickness (min 9 mm) peripheral cortical support used in 274 cases. Fourteen revisions were required for: screwing problems in three cases early in our experience, three loosenings, three inappropriate indications, two patellar problems, one deterioration of the other compartment, one knee instability on an oblique plateau and unexplained residual knee pain. There was no evidence of significant polyethylene wear, even for the oldest cases in our series.

Conclusion: This long-term analysis of single-compartment knee prostheses has shown that at the tibial level the essential elements are the minimal thickness of the polyethylene, the type of sterilisation, and the type of metal back. Resurfaced condyles have demonstrated their superiority over those requiring a resection since only one femoral loosening was observed. Revision for total knee arthroplasty is not different from first intention replacements.

Purpose: External fixators are widely used for limb lengthening procedures. More recently the femoral nail has been introduced combining the advantages of progressive lengthening obtained with external fixation and of the percutaneous approach of internal fixation. This retrospective analysis of 14 patients treated with the progressive femur lengthening nail (ECMP) Albizzia®, was conducted to analyse results in terms of limb length correction, bone healing and complications.

Material and methods: The fourteen patients, nine men and five women, mean age 27.3 years had leg length discrepancies = 20 cm. All were treated with the ECMAP nail (Albizzia®)in January or February 2000. There were nine right legs and five left legs. The patients had discrepancy subsequent to trauma (64.3%), hip dysplasia (21.4%) or neurological (7.15%) or infantile (7.15%) conditions. Mean leg length discrepancy was 41.5mm (20–150 mm); 57.1% of the patients wore a raised heal and 14.2% used crutches. The nail was inserted with reaming and locked on both ends. The corticotomy was made with an endomedullary saw in a closed procedure for 78.5% of the patients and with an open procedure for 21.5%. Angular correction was associated in 32.7% of the cases. Outcome was analysed on the basis of operative time, blood loss, rhythm and amount of limb lengthening, delay to healing and complications.

Results: Mean follow-up was 25 months. Mean operative time was 2 hr 28 min. The lengthening procedure began 4.1 days after nailing with, on the average, 20 ratchet clicks per day. Mean duration of the lengthening procedure was 32.5 days. Mean lengthening was 32.15 mm, i.e. 0.99 mm/day. Ten patients had a general anaesthesia at least twice to manipulate the nail ratchet. There were five cases with mechanical complications and one case of regressive nerve injury. There were no infections, no cases of joint stiffness and no axis defects. Bone healing was achieved a mean 2.7 days. There was one nonunion. Mean haemoglobin loss was four points, three patients required transfusion. Limb length was equivalent in six patients, with < 5 mm discrepancy in three, 6–10 mm discrepancy in one, 11 mm discrepancy in two and 64 mm discrepancy in one. One lengthening procedure had to be interrupted before term.

Discussion: ECMAP is unable to avoid the complications inherent in lengthening procedures but does offer undeniable advantages over external fixation. The risk of infection is very low and skin scars are minimal. Patient comfort is greatly improved (elimination of the cumbersome external fixator). Delay to bone healing is satisfactory and axial rotation defects can easily be corrected. This technique appears to be an excellent means for lengthening the femur in trauma patients.