The diagnosis of infection following shoulder arthroplasty is notoriously difficult. The prevalence of prosthetic shoulder infection after arthroplasty ranges from 3.9 – 15.4% and the most common infective organism is Cutibacterium acnes. Current preoperative diagnostic tests fail to provide a reliable means of diagnosis including WBC, ESR, CRP and joint aspiration. Fluoroscopic-guided percutaneous synovial biopsy (PSB) has previously been reported in the context of a pilot study and demonstrated promising results. The purpose of this study was to determine the diagnostic accuracy of percutaneous synovial biopsy compared with open culture results (gold standard).

This was a multicenter prospective cohort study involving four sites and 98 patients who underwent revision shoulder arthroplasty. The cohort was 60% female with a mean age was 65 years (range 36-83 years). Enrollment occurred between June 2014 and November 2021. Pre-operative fluoroscopy-guided synovial biopsies were carried out by musculoskeletal radiologists prior to revision surgery. A minimum of five synovial capsular tissue biopsies were obtained from five separate regions in the shoulder. Revision shoulder arthroplasty was performed by fellowship-trained shoulder surgeons. Intraoperative tissue samples were taken from five regions of the joint capsule during revision surgery.

Of 98 patients who underwent revision surgery, 71 patients underwent both the synovial biopsy and open biopsy at time of revision surgery. Nineteen percent had positive infection based on PSB, and 22% had confirmed culture positive infections based on intra-operative tissue sampling. The diagnostic accuracy of PSB compared with open biopsy results were as follows: sensitivity 0.37 (95%CI 0.13-0.61), specificity 0.81 (95%CI 0.7-0.91), positive predictive value 0.37 (95%CI 0.13 – 0.61), negative predictive value 0.81 (95%CI 0.70-0.91), positive likelihood ratio 1.98 and negative likelihood ratio 0.77.

A patient with a positive pre-operative PSB undergoing revision surgery had an 37% probability of having true positive infection. A patient with a negative pre-operative PSB has an 81% chance of being infection-free. PSB appears to be of value mainly in ruling out the presence of peri-prosthetic infection. However, poor likelihood ratios suggest that other ancillary tests are required in the pre-operative workup of the potentially infected patient.

Recurrent anterior shoulder instability (RASI) is related to progressive bone loss on the glenoid and on the humeral head. Bone deficit magnitude is a well-recognized predictor of recurrence of instability after an arthroscopic Bankart surgery, but the best way to measure it is unknown. In this study, we want to determine which measurement method is the best predictor of recurrence of instability and function.

For 10 years now, all patients undergoing surgery for RASI in 4 centers are included in a prospective study: the LUXE cohort. Patients with a pre-operative CT-scan and a minimum of 1-year follow-up were included. ISIS score was used to stratify patients. WOSI and Quick-Dash questionnaires were used to characterise function. Bone defects were assessed using the Clock method, the Glenoid Ratio, the Humeral Ratio, the Glenoid Track method and the angle of engagement in the axial plane.

A total of 262 patients are now included in the LUXE study. One hundred and three patients met the inclusion criteria for analysis with a majority of male (79%) and a mean age is 28 years old. The median number of dislocations prior to surgery was 6. Seventy patients had an arthroscopic Bankart repair and 33 patients underwent an open Latarjet procedure. The ISIS score for these groups were of 2.7 and 4.8 respectively (p<0.001). The mean bone defect on the glenoid was of 1h51 with the Clock method (range: 0h-4h48; SD=1h46) and of 9% for the glenoid ratio (0–37%, 10%). On the humeral side, the bone defect was of 1h59 (0h-4h08; 0h49) for the Humeral clock method, 15% (0–36%; 6%) with the ratio method and 71 degrees of external rotation (SD=30 degrees) with the angle of engagement measurement. On the combined evaluations, 53 patients presented an off-track lesion, with mean combined hours of 3h53 (SD= 2h13). The greatest correlation obtained was between the glenoid ratio and the glenoid clock method (r=0.919, p<0.001). Eighteen patients had a recurrence of shoulder dislocation after the initial surgery, leading to a recurrence rate of 23% in arthroscopic surgery versus six percent after a Latarjet (OR= 4.6, p=0.034). No bone defect was correlated to Latarjet failure. For the arthroscopic group, the risk of recurrence was related to a smaller angle of engagement of the Hill-Sachs (p=0.05), a smaller Humeral clock measurement (p=0.034) and a longer follow-up (p=0.006). No glenoid or combined measurements were correlated with arthroscopic procedure failure. Recurrence of dislocation was associated to worst function according to the WOSI (1036 vs 573, p=0.002) and DASH (32 vs 15, p=0.03).

Even with lower ISIS score, arthroscopic procedures are still leading to high risk of recurrence in this “all comer” consecutive cohort study AND it is related to humeral side parameters. Recurrence is also affecting daily function and creating higher anxiety related to the shoulder.

Acute pain is one of the most common symptoms shared among patients who have suffered from an orthopedic trauma such as an isolated upper limb fracture (IULF). Development of interventions with limited side effects aiming to prevent the installation of chronic pain is critical as persistent pain is associated with an increased risk of opioid dependence, medical complications, staggering financial burdens and diminished quality of life. Theta burst stimulation (TBS), a non-invasive magnetic brain stimulation technique with minimal side effects, has shown promising results in patients experiencing various types of chronic pain conditions as it precisely targets brain regions involved in pain processing. Surprisingly, its impact on acute pain has never been investigated. This study aims to assess longitudinal effects of a 10-day continuous TBS (cTBS) protocol applied in the acute phase of an IULF on key functional outcomes.

Patients with an IULF aged between 18 to 60 years old were recruited within 7 days post-accident at a Level I Trauma Center. Exclusion criteria included a history of brain injury, neurological disorders, musculoskeletal complications, and open fractures. In order to assess longitudinal changes, questionnaires measuring intensity and characteristics of pain (Numerical Rating Scale, NRS; McGill Pain Questionnaire, MPQ) as well as functional disability (DASH) were completed by all patients at three time points, namely prior to the start of the TBS program as well as 72 hours and 3 months post-intervention. Patients were randomly attributed to the active TBS protocol (active group) or to the placebo protocol (sham group). The stimulation site for each participant corresponded to the contralateral motor cortex of the injured arm.

Fifty patients were recruited (female: 24; age: 40.38 years old), of which 25 were in the active group and 25 were in the sham group. Both groups were equivalent based on age, sex, type of injury, and surgical procedures (p>0.05). The intervention protocol was introduced on average 6.18 days post-accident. In comparison to the sham group, the active group showed a significant decrease in pain intensity (NRS) at 72h (F=6.02; p=0.02) and 3-month (F=6.37; p=0.02) post-intervention. No group difference was found early-on (72h post) in regard to pain characteristics (MPQ; F=3.90; p=0.06) and functional disabilities (DASH; F=0.48; p= 0.49). At three-month post-intervention, the active group showed statistically significant improvement on the MPQ (F=5.02; p=0.04) and the DASH (F=5.88; p=0.02) compared to the placebo group. No complications related to the treatment were reported.

Results from this study show that patients who underwent active cTBS reported less pain and better functional states shortly after the end of the TBS protocol compared to sham patients and treatment effects were maintained at three months post-intervention. Given that acute pain intensity is an excellent predictor of chronic pain development, this safe technique available in numerous centers in Canada may help prevent chronic pain development when administered during the acute post-injury phase. Future studies should continue to investigate mechanisms involved to optimize this technique among the orthopedic trauma population and to reduce opioid consumption.

Radial head fractures are relatively common, representing approximately one-third of all elbow fractures. Outcomes are generally inversely proportional to the amount of force involved in the mechanism of injury, with simple fractures doing better than more comminuted ones. However, the prognosis for these fractures may also be influenced by associated injuries and patient-related factors (age, body index mass, gender, tobacco habit, etc.) The purpose of this study is to evaluate which factors will affect range of motion and function in partial radial head fractures. The hypothesis is that conservative treatment yields better outcomes.

This retrospective comparative cohort study included 43 adult volunteers with partial radial head fracture, a minimum one-year follow up, separated into a surgical and non-surgical group. Risk factors were: associated injury, heterotopic ossification, worker's compensation, and proximal radio-ulnar joint implication. Outcomes included radiographic range of motion measurement, demographic data, and quality of life questionnaires (PREE, Q-DASH, MEPS).

Mean follow up was 3.5 years (1–7 years). Thirty patients (70%) had associated injuries with decreased elbow extension (−11°, p=0.004) and total range of motion (−14°, p=0.002) compared to the other group. Heterotopic ossification was associated with decreased elbow flexion (−9°, p=0.001) and fractures involved the proximal radio-ulnar joint in 88% of patients. Only worker's compensation was associated with worse scores. There was no difference in terms of function and outcome between patients treated nonsurgically or surgically.

We found that associated injuries, worker's compensation and the presence of heterotopic ossification were the only factors correlated with a worse prognosis in this cohort of patients. Given these results, the authors reiterate the importance of being vigilant to associated injuries.

Treatment of proximal humerus fractures (PHF) is controversial in many respects, including the choice of surgical approach for fixation when using a locking plate. The classic deltopectoral (DP) approach is believed to increase the risk of avascular necrosis while making access to the greater tuberosity more difficult. The deltoid split (DS) approach was developed to respect minimally invasive surgery principles. The purpose of the present study (NCT-00612391) was to compare outcomes of PHF treated by DP and DS approaches in terms of function (Q-DASH, Constant score), quality of life (SF12), and complications in a prospective randomized multicenter study.

From 2007 to 2016, all patients meeting the inclusion/exclusion criteria in two University Trauma Centers were invited to participate in the study. Inclusion criteria were: PHF Neer II/III, isolated injury, skeletal maturity, speaking French or English, available for follow-up (FU), and ability to fill questionnaires. Exclusion criteria: Pre-existing pathology to the limb, patient-refusing or too ill to undergo surgery, patient needing another type of treatment (nail, arthroplasty), axillary nerve impairment, open fracture. After consent, patients were randomized to one of the two treatments using the dark envelope method. Pre-injury status was documented by questionnaires (SF12, Q-DASH, Constant score). Range of motion was assessed. Patients were followed at two weeks, six weeks, 3-6-12-18-24 months. Power calculation was done with primary outcome: Q-DASH.

A total of 92 patients were randomised in the study and 83 patients were followed for a minimum of 12 months. The mean age was 62 y.o. (+- 14 y.) and 77% were females. There was an equivalent number of Neer II and III, 53% and 47% respectively. Mean FU was of 26 months. Forty-four patients were randomized to the DS and 39 to the DP approach. Groups were equivalent in terms of age, gender, BMI, severity of fracture and pre-injury scores. All clinical outcome measures were in favor of the deltopectoral approach. Primary outcome measure, Q-DASH, was better statistically and clinically in the DP group (12 vs 26, p=0,003). Patients with DP had less pain and better quality of life scores than with DS (VAS 1/10 vs 2/10 p=0,019 and SF12M 56 vs 51, p=0,049, respectively). Constant-Murley score was higher in the DP group (73 vs 60, p=0,014). However, active external rotation was better with the DS approach (45° vs 35°). There were more complications in DS patients, with four screw cut-outs vs zero, four avascular necrosis vs one, and five reoperations vs two. Calcar screws were used for a majority of DP fixations (57%) vs a minority of DS (27%) (p=0,012).

The primary hypothesis on the superiority of the deltoid split incision was rebutted. Functional outcome, quality of life, pain, and risk of complication favoured the classic deltopectoral approach. Active external rotation was the only outcome better with DS. We believe that the difficulty of adding calcar screws and intramuscular dissection in the DS approach were partly responsible for this difference. The DP approach should be used during Neer II and III PHF fixation.

Treat to target is the use of a physiologic marker as a monitor of effectiveness or compliance to an intervention. A recent example has been the progressive use of CTX-1 (Marker of osteoclastic activity) as a surrogate of bone resorptive activity in osteoporosis treatment. CTX-1 levels were demonstrated to be inversely related to drug efficacy in the suppression of bone resorption. As far as fragility fractures are concerned, no reference value of CTX-1 for any index fracture sites was found in the literature. In order to prevent subsequent fractures, efforts to better manage this chronic disease are to be explored. The main objective of this study was to compare and validate the use of serum CTX-1 to the perceived compliance to treatment.

Five hundred and forty three patients (men and women) 40 years of age or older who had been treated for a fragility fracture were enrolled. The purpose of this study was to correlate the measurement of CTX-1 with the perceived compliance to treatment of patients at the time of fracture and at six, 12 and 18 months after initiation of treatment. Our secondary objectives were to evaluate two different CTX-1 suppression target levels (CTX-1< 0.3 ng/mL and CTX-1<0.2 ng/mL), to determine CTX-1 values according to fracture sites, and to explore the profile of patients with subsequent fractures.

Considering index fractures, compliant patients under treatment at baseline had lower CTX-1 levels than non-compliant patients (p=0.052). Patients who were compliant to treatment at six, 12 and 18 months also had lower CTX-1 levels than non-compliant patients (p=0.000). When index fractures were divided into fracture sites, regardless of CTX-1 suppression target level (i.e. CTX-1< 0.3 or 0.2 ng/mL), significant CTX-1 suppression was observed in non-hip and non-vertebral (NHNV) fractures at six, 12 and 18 months (p0.05). No clinically relevant difference was observed between the profile of patients with and without subsequent fractures.

The correlation between serum CTX-1 at the time of fracture and at six, 12, 18 months and the perceived compliance to treatment was validated for NHNV fractures supporting the concept of the available treatments and their effects on bone remodeling for this type of fracture. The correlation was not validated for hip neither for vertebral fracture. There was no correlation between CTX-1 levels and subsequent fracture risk.

Reoperations may be a better way of tracking adverse outcomes than complications. Repeat surgery causes cost to the system, and often indicate failure of the primary procedure resulting in the patient not achieving the expected improvement in pain and function. Understanding the cause of repeat surgery at the primary site may result in design improvements to implants or improvements to fusion techniques resulting in better outcomes in the future. The COFAS group have designed a reoperation classification system. The purpose of this study was to outline the inter and intra observer reliability of this classification scheme.

To verify the inter- and intra-observer reliability of this new coding system, six fellow ship trained practicing foot and ankle Orthopaedic surgeons were asked to classify 62 repeat surgeries from a single surgeons practice. The six surgeons read the operation reports in random order, and reread the reports 2 weeks later in a different order. Reliability was determined using intraclass correlation coefficients (ICC) and proportions of agreement. The agreement between pairs of readings (915 for inter observer for the first and second read – 61 readings with 15 comparisons, observer 1 with observer 2, observer 1 with observer 3, etc) was determined by seeing how often each observer agreed. This was repeated for the 366 ratings for intra observer readings (61 times 6).

The inter-observer reliability on the first read had a mean intra-class correlation coefficient (ICC) of 0.89. The range for the 15 comparisons was 0.81 to 1.0. Amongst all 1830 paired codings between two observers, 1605 (88%) were in agreement. Across the 61 cases, 45 (74%) were given the same code by all six observers. However, the difference when present was larger with more observers not agreeing. The inter-observer reliability test on the second read had a mean ICC of 0.94, with a range of 0.90. There were 43 (72%) observations that were the same across all six observers. Of all pairs (915 in total) there was agreement in 804 pairs for the first reading (88%) and disagreement in 111 (12%). For the second reading there was agreement in 801 pairs (86%) and disagreement in 114 (14%). The intra-observer reliability averaged an ICC value of 0.92, with a range of 0.86 to 0.98. The observers agreed with their own previous observations 324 times out of 366 paired readings (89% agreement of pairs).

The COFAS classification of reoperations for end stage ankle arthritis was reliable. This scheme potentially could be applied to other areas of Orthopaedic surgery and should replace the Claiden Dindo modifications that do not accurately reflect Orthopaedic outcomes. As complications are hard to define and lack consistent terminology reoperations and resource utilisation (extra clinic visits, extra days in hospital and extra hours of surgery) may be more reliable measures of the negative effects of surgery.

Purpose: Recognition of the proximal ulna dorsal angulation (PUDA) is important for anatomic reduction of proximal ulnar fractures or osteotomies, especially when using newer straight precontoured proximal ulnar plates. The purpose of this study was to characterize the PUDA in 50 patients with bilateral elbow radiographs.

Method: Bilateral elbow radiographs (100 radiographs) were magnified four times using commercial software. The PUDA was measured from the intersection of lines tangent to the subcutaneous border of the olecranon and the proximal ulnar shaft. The olecranon tip-to-apex distance of the PUDA was also measured. Three orthopaedic surgeons independently examined the radiographs and intra/inter-observer reliability was calculated using Intra-Class-Correlation (ICC).

Results: A PUDA was present in 96% of radiographs. The average PUDA was 5.7° (range, 0°to14°). The Pearson Correlation coefficient for a side-to-side comparison was 0.86(p< 0.001). The average tip-to-apex distance was 47 mm (34 mm–78mm). No correlation was identified with sex or age. Intra-observer reliability was excellent for the PUDA (ICC 0.892 and 0.863) and good for tip-to-apex distance (ICC 0.762 and 0.827). Inter-observer reliability was good for PUDA (ICC 0.784 and 0.925) and for tip-to-apex distance (ICC 0.711 and 0.769).

Conclusion: A mean proximal ulna dorsal angulation of 5.7° is present in 96% of patients at an average of 47 mm distal to the olecranon tip. Measurement of the PUDA has good/excellent inter/intra-observer reliability. Recognition of the PUDA may be helpful in anatomic plating of the ulna. Contralateral PUDA measurements are useful for surgical planning in cases with comminution or distorted anatomy.

Purpose: Lors de la réduction chirurgicale des fractures de la cheville avec instabilité syndesmotique, le chirurgien se fie généralement sur les vues de mortaise et antéro-postérieure. Toutefois, une subluxation ou luxation antérieure du péroné par rapport au tibia distal peu survenir et passer inaperçu (trois exemples cliniques prouvés par CT Scan post-opératoire), spécialement lors de la pose de vis syndesmotique(s). La présente étude a pour but d’établir la relation radiologique précise sur une vue latérale fluoroscopique entre les tibia et péroné distaux qui permettra au chirurgien de confirmer en peropératoire que l’articulation tibio-péronière distale est bel et bien réduite.

Method: Les chevilles normales de trente volontaires sans antécédent de traumatisme ou de maladie de la cheville ont été imagées sous une vue latérale fluoroscopique parfaite, avec un Mini C-Arm. Les images ont été analysées et comparées entre elle afin d’établir une relation radiologique fiable et reproductible entre le tibia et le péroné distaux.

Results: Dans les trente cas, il y avait intersection du milieu de la cicatrice physaire et du cortex antérieur du péroné. Cette relation a été trouvée statistiquement significative.

Conclusion: La réduction chirurgicale parfaite de l’articulation tibio-péronière distale peut être confirmée avec une vue latérale fluoroscopique de la cheville. Le cortex antérieur du péroné doit toucher le milieu de la cicatrice physaire.

Purpose: Nerve re-generation and functional recovery are often incomplete after a peripheral nerve lesion. The aim of this study was to determine if the injection of chondrotinase ABC at the lesion site, one hour of electrical stimulation, and the combination of these treatments at the time of repair are effective in promoting nerve regeneration and muscle re-innervation.

Method: A complete right sciatic nerve section was done on 32 female Sprague-Dawley rats. End-to-end microsuture repair was performed and fibrin glue was added. Five groups were studied:

Sutures and Fibrine glue (S+F),

Results: Side video kinematics was performed and a larger excursion of the hip-ankle-toe angle during walking was showed in groups 2, 3, and 4. (p< 0.05) At 150 days, in-vivo EMg activity and maximal muscle force were similar in group 2, 3, 4, 5 and all of them were higher compared to group 1 (p< 0.05). Histological study revealed equivalent number of axone in all group and pore correlation with nerve function.

Conclusion: In conclusion, five months after nerve transection, the recovery is incomplete when using suture and fibrine glue only. Moreover, an injection of chondrotinase ABC at the lesion site and/or one hour of electrical stimulation of the proximal nerve stump is beneficial in promoting nerve regeneration and functional muscle re-innervation.

Purpose: Musculoskeletal injuries affect up to 13% of adults annually. Despite this high incidence, quality of primary care, including analgesia, may be sub-optimal. The goal of this study is to describe the quality of primary care for ambulatory patients with isolated limb injury and to identify related factors.

Method: A cross sectional study was undertaken on 166 consecutive ambulatory adult patients with isolated limb injury who presented to orthopedics service in a Level one Trauma Centre. Quality of care was assessed by evaluating analgesia, walking aids, immobilization, and quality of referral diagnosis according to actual expert recommendations. Patient satisfaction was assessed by Visit Satisfaction Questionnaire.

Results: This study revealed low quality of primary care for more than 50% of injured patients. More than half the patients had pain level over 5/10 and more than a quarter had insufficient/absent analgesia prescriptions. A third had unacceptable immobilization and 36% of patients with a lower limb injury did not receive a walking aid prescription. A total of 37% had an absent or inadequate referral diagnosis. Factors associated with lower quality depended on the specific quality indicator and included: living further away from the hospital, younger age, initially consulting at another health care center, having a fracture, and being a smoker.

Conclusion: The high frequency of low quality of care underlines the necessity for orthopedic surgeons to be involved in primary care education. Identifying factors associated with lower quality of care will orient efforts to improve medical care of patients with isolated traumatic injury.

Object: Smoking is a negative prognostic factor in the outcome of some fractures. We evaluated whether smoking is associated with primary care quality and referral to orthopedic surgeons for an isolated injury.

Materials and Methods: We enrolled all new ambulatory cases with an isolated injury to an extremity referred to an orthopedic trauma clinic. Data were analyzed concerning: type of trauma, prior medical consultations, quality of initial management, patient characteristics and smoking status.

Results: Among 166 consecutive patients referred, 45 were smokers. Family income was under $30 000 for 44% of smokers compared to 27% for non-smokers (p< 0,05). Smokers were younger (43 y.o. vs 50 y.o.; p< 0,05) and used illegal drugs more often (16% vs 5%; p< 0,05). Smokers were more likely to have been injured at work while non -smokers reported their injury as a sport accident. Injury severity, type of injury and ethnic characteristics were not different. Smokers were twice as likely to receive an unacceptable immobilization for their injury than non-smokers (52% vs 25%; p< 0,05) and received inadequate walking aids (26% vs 9%;0< 0,05). Delay from first primary care consultation to orthopedic appointment was almost 2 times longer for smokers (93hrs vs 58hrs; p< 0,05).

Discussion and Conclusion: Injured smokers received a lower standard of care and had longer delays for orthopedic consultations. Primary care quality and efficiency were associated with smoking status, possibly due to medical bias or incorrect use of health service by patients. Relevance: Smoking is a risk factor for complications in orthopedic surgery. Our results suggest that biology may not be the only explanation.

Hypothesis: Patients with mono-trauma to an extremity often consult primary care prior to being referred to orthopedics services. Appropriate pain control, immobilization and walking aids are not always given to ambulatory patients.

Methods: The study used a prospective trauma database of all new ambulatory cases with an isolated injury to an extremity referred to an orthopedic trauma clinic at a level-one trauma center. Patients arriving by ambulance and those that were not able to filled questionnaires were excluded. Data were collected at the initial visit regarding the type of trauma, the medical consultations prior to orthopedic evaluation, the initial management (cast, walking aids, pain control), patient’s socio-demographic characteristics, and patient satisfaction (Visit-Specific Satisfaction Questionnaire: VSQ).

Results: Our sample consisted of 166 consecutives patients referred for fracture (85%) and soft tissue injury(15%) to an orthopedic trauma clinic. Nearly two-thirds (65%) had upper limb injuries. 47% of patients were referred from the same hospital emergency, while 53% were referred from other hospitals or clinics. In terms of patient perceptions, 50% considered their injury as a serious health problem. The average satisfaction score (VSQ) was 84%. However, 50% of patients had a substantial degree of pain (> 5/10) at the time of orthopaedic consultation. In addition, 30% of patients received no prescription for analgesics and declared that they missed it and 21% who received a prescription claimed it was not sufficient to decrease their pain. Of those who required immobilization following the type of injury, 30% received none or it was unsuitable. 1/6 of patients who required crutches/cane/wheelchair for a lower limb injury had none prescribed.

Conclusion: Primary care for persons with mono-trauma was suboptimal in terms of pain control and immobilization for more then 40% of patients. General practitioners showed a lack of basic knowledge on the importance of initial treatment of isolated limb injury.

Significance: Isolated fractures are a common problem affecting a large amount of the population. This study identified unacceptable rate of poor initial management for simple injury. Orthopedic trauma surgeon must be informed of this reality and then, becoming more involved in primary care education in their own health care network.

Plate fixation of the proximal humerus fractures may now be more desirable with the use of a biological approach by limiting surgical insult and allowing accelerated rehabilitation by a solid fixation. To evaluate the safety and efficacy of minimally invasive plating of the proximal humerus using validated disease-specific measures.

During a period of one year, thirty patients were operated with use of the LCP proximal humerus plate (Synthes) through a 3cm lateral deltoid splitting approach and a second 2 cm incision at the deltoid insertion. The axillary nerve was palped and easily protected during insertion. Only two-part (N=22) and three-part impacted valgus type (N=8) were included in this study since they can be reduced indirectly thru this percutaneous technique. The average follow-up was thirteen months (eight to twenty months). All patients had the Constant and DASH evaluations.

All fractures healed within the first six months with no loss of correction. The surgical technique was found easy by all surgeons, the axillary nerve was palpated and protect with this new technique. No infection or avascular necrosis were seen. No axillary nerve deficit was identified. At the last follow-up (average nineteen months, twelve months minimum), the median Constant score was sixty-eight points, with an age ajusted score of seventy-six. The mean DASH score was twenty-seven points. Only age was independently predictive of both the Constant and DASH functional scores. Patients improved until one year of follow up.

Percutaneous insertion of a locking proximal humerus plate is safe and produces gives good early functional and radiologic outcomes. Recuperation from a proximal humerus fracture can be seen until one year.

Purpose: Restoration and maintenance of the plateau surface are the key points in the treatment of tibial plateau fractures. Any deformity of the articular surface jeopardizes the future of the knee by causing osteoarthritis and axis deviation. The purpose of this study is to evaluate the effect of trabecular metal (porous tantalum metal) on stability and strength of fracture repair in the central depression tibial plateau fracture.

Method: Six matched pairs of fresh frozen human cadaveric tibias were fractured and randomly assigned to be treated with either the standard of treatment (impacted cancellous bone graft stabilized by two 4.5mm screws under the comminuted articular surface) or the experimental method (the same screws supporting a 2 cm diameter Trabecular Metal (TM) disc placed under the comminuted articular surface). Each tibia was tested on a MTS machine simulating immediate postoperative load transmission with 500 Newton for 10000 cycles and then loaded to failure to determine the ultimate strength of the construct. Results: The trabecular metal construct showed 40% less caudad displacement of the articular surface (1, 32 ±0.1 mm vs. 0, 80 ±0.1 mm) in cyclic loading (p< 0.05). Its mechanical failure occurred at a mean of 3275 N compared to 2650 N for the standard of care construct (p< 0, 05).

Conclusion: The current study shows the biomechanical superiority of the trabecular metal construct compared to the current standard of treatment with regards to both its resistance to caudad displacement of the articular surface in cyclic loading and its strength at load to failure.

Objective: Revision total hip arthroplasty in cases of proximal femoral bone loss due to osteolysis and loosening is challenging for surgeon and implants. The use of tapered fluted modular titanium femoral stem in these situations may offer the advantage of better biomechanical reconstruction with a design that ensure primary stability and promotes bone integration.

Method: We studied retrospectively 83 cases of femoral reconstruction with the PFM-R stem. Paprosky classification was used to qualify bone defects on preoperative radiological evaluation. Demographic, clinical and intraoperative data were collected, along with any complications. Clinical (W.O.M.A.C. function score) and radiological follow-up was performed at a minimum of 12 months.

Results: The mean follow-up was 44 months (23 to 66 months). Five patients were lost to follow-up. 48% of patients had at least one previous revision. The mean post operative WOMAC score was 83. 91% of patients had no significant limb length discrepancy. Stabilization or regression of osteolytic lesions was observed in 75% of revised femur. Complications were 8 dislocations, 7 fractures and 3 infections. A correlation was found between the risk of dislocation and the number of previous revision surgery. Out of 14 cases revised for infection, one had a recurrence.

Discussion: This study confirmed the benefits of the PFM-R stem in difficult femoral revision in term of limb length equalization, stability of fixation, regression of osteolytic lesions and improved clinical function.