Aim: The operative management of proximal humerus fractures is still viewed as an unsolved question.

Surgical treatment aims at restoring anatomical elements to a condition stable enough, to allow early mobilization to avoid secondary displacement. The blood supply of the humeral head should not be damaged, so the risk of avascular necrosis will be minimal.

This work offers a new surgical technique that dramatically reduces the need for dissection of soft tissues while using a new locked plate.

Material and Method: This prospective study was carried out between August 2002 and March 2004. 47 fractures of the humerus proximal were operated on 47 patients aged 63 as an average. There were 9 four part fractures, 18 three part and 17 two part fractures.

The two arms of this Y shaped plate embrace the humeral head. The anterior arm overbridges the biceps longus tendon and fixes the lesser tuberosity, with a locked screw in the head. The posterior arm fixes the greater tuberosity with an another locked screw. These two screws cross each other at nearly right angle thus giving optimal fixation in the head.

Results: Fourty four patients (44 shoulders) were later re-examined with 10,3 months mean delay. Re-education was made immediate for 85% of the cases. The final evaluation was made with the functional Constant score and X ray control.

The main complications were 3 algodystrophies, 1 hematoma, 4 failures of fixation, 2 nonunions and only one necrosis.

Conclusion: This first clinical experience with this new implant is stimulating, since it provides a reliable fixation, even into the osteopenic bone.

Purpose: We tested the reliability of a digitalised x-ray reading system, Imagika(r), used to measure linear wear of total hip arthroplasy on the AP view of the pelvis.

Material and methods: Wear measurements were taken for total hip arthroplasties without cement (n=20) and with cement (n=19) using the distance between the centre of the acetabular cup and the femoral ball. The system delivered measures in hundredths of millimetres that were rounded off to the nearest tenth millimetre. For non-cemented implants, the centre of the acetabular cup was found automatically on the digitalised radiograms using the contour of the metal socket. For cemented cups, the centre of the cup was determined from five points situated on the metallic ellipse included in the polyethylene circumference. The software placed the point clicked by the reader on the adjacent intermediary zone showing the greatest contrast. Five observers read the radiograms twice at 15 day intervals. The observers were a young resident, a senior traumatology surgeon,and a senior surgeon specialised in hip surgery. Results were compared to determine inter- and intra- observer variability.

Results: Intra-observer variability was low since the standard deviation (at alpha error set at 5%) ranged from one tenth of a millimetre to six-tenths of a millimetre for four observers. It was higher (2 millimetres) for the fourth observer. The younger observers achieved the best reproducibility, to the order of a tenth of millimetre. Conversely, interobserver variability was high with standard deviation of several millimetres for an alpha risk of 5%. Comparing the two observers who achieved the best performances, the standard deviation of the measures was in the 3 to 4 millimetre range.

Discussion: Measurement precision was greater for cemented cups. Conversely, for press-fit cups, the contour of the head was sometimes difficult to distinguish even with optimal contrast and measurement deviations were to the order of one millimetre.

Conclusion: The reproducibility of the Imagika(r) system is insufficient to measure wear of total hip arthroplasty where the precision must be to the order of a tenth of a millimetre.

Purpose: We report our first cases of retrograde nailing using the universal humerus nail (UHN).

Material and methods: Fifty patients (26 men and 24 women), mean age 60.2 years, with fracture of the humerus were treated with the UHN; most had shaft fractures, 40 were trauma victims, and ten had metastases.

Retrograde nailing was achieved by trepanation of the apex of the olecranon fossa. Proximal or distal locking was applied in all cases using one or more screws. Outcome was assessed with the S.O.O. criteria (1996).

Results: Two patients were lost to follow-up and two patients died early. Forty-six patients were reviewed with a mean follow-up of six months (range 3–18). Outcome was very good or good in 43 patients (bone healing at three months), fair in one, poor in two (two constructs dismounted at day 15); three asymptomatic fractures did not heal at one year (all healed two months after compression). Peroperative complications included: four fissures of the posterior cortical at the entry window and two supracondylar fractures. One patient developed radial palsy in the immediate postoperative period that resolved spontaneously. One of the proximal locking screws loosened early in four patients. Finally, one patient developed a supracondylar fracture at the point of entry following a fall four months after the nailed fracture had healed.

Discussion: The two cases of dismounting were subtuberosity fractures in elderly patients; likewise the one fair outcome was a minimal secondary displacement that had not healed at five months. The proximal locking screws did not hold well in osteoporotic heads explaining the three cases of early screw loosening. Impacting the curved nail into the last centimeters is a delicate operation and we had two fissures of the posterior cortical and peroperative supracondylar fractures early in our experience. Finally, the absence of an aiming device for the proximal locking screw complicates this procedure. The possibility for orthogonal proximal locking is however an advantage for rotatory stability. This nail allows early rehabilitation without mobilisation.

Conclusion: Retrograde locked nailing provides good results at three months for humeral shaft fractures. Subtuberosity fractures in elderly patients are not good indications. A straight nail would however be preferable and an aiming device for the proximal locking would be useful.

Purpose: We wanted to ascertain whether the advantages of functional treatment on trophicity could be combined with the advantages of surgical treatment on anatomic results in patients with displaced calcaneal join fractures.

Material and methods: Using the AO 3.5 reconstruction plates with specific stereotypic modelling we were able to obtain solid fixation in almost all cases of calcaneal joint fractures using a rigorous technique and following precise principles, notably the direction of the screw into the sustentaculum tali.As the osteosynthesis is very stable, we postulate that partial and progressive early weight bearing would be acceptable as long as pain was under a threshold level used as sign of micromobility. The first cases were very favourable so we extended this method, using it as a routine procedure for all cases (excepting those with an associated injury excluding weight bearing). Among 122 fractures operated with this method, 118 were reviewed.

Results: According to the Duparc classification, we treated one type 2, 34 type 3, 76 type 4 and seven type 5 fractures. Weight bearing was initiated on the average at 14 days, with a median of seven days. The Boehler angle improved from 0° preoperatively to 22° postoperatively. We did not have any cases of secondary displacement greater than 2°. The functional outcome was, according to the SOFCOT criteria: very good 34.5%, good 41.4%, fair 9.5% and poor 0%. Physical results (SOFCOT criteria) were: very good 17.2%, good 54.3%, fair 26.7%, poor 1.7%. Anatomic results according to AFC criteria were: very good and good 69%, fair 25.9%, poor 5.1%.

Discussion: These result demonstrate that a rigorous therapeutic management scheme can combine the advantages of functional and surgical treatment of displaced calcaneal joint fractures. Early weight-bearing below the pain threshold was effective since all our bilateral cases could be discharged after walking a few steps. Recovery was more rapid when weight bearing was late. Crutches could be abandoned at two months on the average.

Conclusion: We believe that solid osteosynthesis is possible in almost all cases of displaced calcaneal fractures with joint involvement if a rigorous technique is used. Progressive early weight bearing below the pain threshold is a significant adjuvant factor favouring rapid and quality outcome.