Purpose: Publications reporting compression flexion fractures are rather old and rarely individualise this type of fracture. There is a consensus on anterior plate fixation which generally provides good outcome. We propose a retrospective analysis of our series to revisit the classification system and analyse outcome after surgical treatment.

Material and methods: From January 1983 to November 2001, 96 fractures of the lower extremity of the radius with anterior displacement were treated in our unit. There were 95 patients (50 men and 45 women), mean age 42.7 years (15–88). The fracture resulted from a traffic accident in 52 patients. Twenty-seven patients had associated injuries. For lateral simple or complex anterior marginal fractures, the Castaing and Cauchoix classification was modified to take into account the importance of the fragment, relative to the middle of the radial glenoid, with or without associated lesion of the radial borders on the lateral and AP views (types I and II fractures). Type III factures were Goyrand fractures and type IV associated Goyrand fractures with one or more joint fracture lines. Our series thus included 43 anterior marginal fractures including 27 type II fractures where more than 50% of the joint surface was displaced, 53 Goyrand fractures (25 type III and 28 type IV). Plate fixation was used for 90 wrists, associated with complementary fixation in 17. Outcome was assessed with Laulan clinical criteria and Mouilleron radiological criteria.

Results: Bone healing was achieved in all cases, without changing the initial fixation in 85 wrists. There were 49 men and 35 women, mean age 40.7 years (20–87). Type I/II fractures were found in 40 wrists, simple Goyrand fracture (type III) in 23 and comminuted Goyard fracture (type IV) in 22. At three months, reduction was good in 57 cases (67%), fair in 23 and poor in five.There were eleven secondary displacements in eight women and three men, mean age 57.7 years. They had four type I/II fractures and seven Goyrand fractures (1 type III, and 6 type IV). Plate fixation used for eight wrists had to be completed with pinning or a fixator. Radiological reduction was good in two cases (18%), fair in three and poor in six (55%). Twenty-five patients (30%) presented residual pain (10 patients), carpal tunnel syndrome (7 patients), wrist or finger stiffness (4 patients), radiocarpal osteoarthritis (3 patients), and cutaneous palmar neuroma (1 patient). At mean 61 follow-up (12–204), clinical outcome was good for 70 wrists; 78 wrists were pain free. The radiological outcome was good in 64 wrists, fair in 18 and poor in five.

Discussion: Better radiographic analysis distinguishing type II and IV fractures, which were the cause of three-quarters of the displacements, improves identification of wrists which must have complementary fixation with pins or fixator in addition to the anterior plate which in these cases should be prebent. For the other wrists, initial reduction was satisfactory in 67%, explaining the good functional tolerance demonstrated subjectively (89%) and objectively (80%). There were only rare sequelae in this series and complications were limited: painful wrist in 10%, secondary to reflex dystrophy in two.

Conclusion: Good interpretation of the radiographs enables prediction of difficult reduction where complementary fixation in addition to the anterior plate can be useful for type II and IV fractures.

Purpose: The long-term outcome of the Harris-Galante 1 (HGP1) stem is a controversial issue. A randomised study reported by Thanner (AOS 1999) mentioned a 72% survival at ten years, basically related to femoral osteolysis observed in 18% of the cases with mechanical failure requiring revision in 20%. We studied the clinical and radiological outcome of 191 HGP1 stems reviewed at a mean 12.5 years.

Material: This prospective study included a consecutive series of 181 patients (191 hips) 101 men and 80 women, mean age 62.1 years (range 19–83). Indication for arthroplasty was primary hip degeneration (80%), or osteonecrosis (14.6%). A metal-backed polyethylene cup and a 28 mm head were inserted in 86% of the cases. At review, 41 patients had died (43 hips), two were lost to follow-up, and x-rays were available for 109. Mean follow-up was 150.2±15.3 months.

Methods: The Postel Merle d’Aubigné (PMA) and Harris (HHS) scores were recorded for all patients. Position and quality of bone fixation were analysed. Stem migration was calculated on the different x-rays by calculating the distance between the centre of the head and the summit of the greater trochanter. Lucent lines (Gruen), osteolysis and the ARA score were noted. The SOFCOT 1997 radioclinical classification was used. Actuarial survival curves were plotted taking stem revision as the endpoint. Quantitative data were compared with the chi-square test.

Results: One patient died on day three. There were three displacements. The PMA pain score improved from 2.5 to 5.6 and the HHS improved from 52.5 to 85.6 points. The stem was perfectly aligned in 80 cases, and presented a varus deviation ≤ 3° in 26 cases. A change in the initial alignment was noted in three cases and stem impaction in 14. Eleven revisions were necessary for fibrous fixation (n=5), pain (n=2), femoral malposition, (n=1), fracture of the femur during the operation (n=1, and diaphyseal osteolysis (n=1). Finally, there were no radiographic anomalies for 69 hips (class A), radiographic anomalies without clinical expression for 34 (class B), basically because of severe osteolysis of the calcar (n=6), and stress shielding in zone 1A-B. Three hips caused pain without a detectable radiographic anomaly (class C), only one hip was in class D because of the poor clinical and radiological result. The 15-year actuarial survival taking stem revision as the endpoint was 89.5±3.7%.

Discussion: The 5% rate of unstable fibrous fixation observed in this series is very different from the 16% reported by Garcia Cimbrelo (2001). There was only one case of femoral shaft osteolysis limited to zone 3 which required revision, contrasting with the 16% (Thanner) and 24% (Garcia Cimbrelo) reported for shorter follow-ups.

Conclusion: With an 89.5% mid-term survival, the Harris Gallante 1 femoral stem has provided good clinical results and a solid fixation due to the proximal porous coating on the titanium. Although rare, stem failure was observed during the first six years of implantation.

Introduction: The purpose of this retrospective study was to evaluate the results of retrograde pinning, according to Hacketal procedure, for unstable fractures of the humeral neck with particular attention to three and four part fractures.

Materials and Methods: Between 7/1990 and 4/2001, we treated 44 patients (26 females and 18 males) ranging in age from 16 to 92 years (mean: 59/5 years). 75% of the cases followed a domestic trauma. Using Neer classification there were 30 two part fractures, 12 three part and 2 four part fractures. After closed reduction was performed under biplane image intensification, a small incision was made to expose the distal humerus by blount dissection. A 5 mm hole was drilled. Three to five prebend Kirschner (25 cases) or Metaizeau pins (19 cases) were introduced retrograde achieving a ‘bouquet’-type fixation within the humeral head. Post operatively, the arm was immobilized in a Mayo-type sling for 2–3 weeks. Then mobilization was started in all directions except rotation, who was cautiously done later. The results were evaluated according to consolidation, pain and range of motion. Complications associated with the treatment were recorded. We considered as excellent results, asymptomatic shoulder with full motion, good results patients with slight pain or reduction of motion and bad results, those with any pain, valuable restriction of motion and functional handicap.

Results: The mean follow up was 21/7 months. Two patients died before callus formation. All patients were re-examined or contacted by phone. No patient was lost to follow-up. The mean hospitalization range was 6.4 days. Two patients had loss of fixation. Fractures united with callus formation in 4 to 8 week. Patients regained a full range of motion in 64% of the cases, 88% were free of pain. No avascular necrosis was noted in that series.

The functional outcome was excellent in 64% of the cases, good in 21.5% of the cases. Pins removal was almost necessary for proximal pins migration in 45% of the cases and distal migration in 7.5% of the cases.

Discussion: The overall finding of good results in this series compares favorably with results of other operative treatment. We believe that our technique offers distinct advantages: few displacement, no osteonecrosis but our follow-up can be considered as insufficient. Migrations of the pins remain a matter of concern.

Conclusion: Retrograde pinning by the olcranon fossea is a demanding technique which makes sense biologically from the stand point of respect of vascularity. It is a useful alternative to open reduction and internal fixation. In three or four part fractures, it has to be tested before primary hemiarthroplasty.

Purpose: Removing cement for revision total hip arthroplasty is always a challenge. The OSCAR device (Orthosonics Ltd UK) provides an elegant solution. We conducted a prospective study of ultrasound ablation using this device in 19 patients undergoing revision total hip arthroplasty to assess feasibility.

Material and methods: Between March 1999 and January 2001, 17 patients, ten women and seven men underwent revision of their femoral component for aseptic loosening (14 cases) or infection (five cases). The Vives criteria as modified by SOFCOT were six grade 1, six grade 2, five grade 3 and two grade 4. The femoral stem removed had a standard length in 17 cases and measured 250 mm in one. The cement obturated the femur in one case with a proximal misinsertion. On the average, the terminal plug went 40 mm beyond the tip of the stem. Trochanterotomy was used ten times and anterior approach in nine. Two ultrasound probes were used: scraper probes that removed cement from the walls and a perforating probe when needed to remove the terminal plug. We recorded the time needed to remove all the cement, the ease or difficulty of the process, the presence of misinserted cement, need for other methods (new window, femorotomy), duration of the hospital stay, and delay to weight-bearing with crutches. The quality of the cementing and presence of cement overflow were determined on plain radiographs. All patients were reviewed for this work.

Results: It took less than 60 min to remove the cement in 14 cases and from 60 to 90 min for four cases; the cement could not be totally removed in one case. There was one fracture (grade 4 during a third revision operation). The end plug was removed under good conditions in 14 cases. The femoral stem could be recemented in nine cases using a longer stem in five. Cementing was satisfactory in 12 cases. Deferred surgery was required for the five cases with infection; in two cases the cement persisted at the second operation requiring a new ablation process. There were no cases of misinsertion. Mean hospital stay was 10.1 days and weight-bearing was authorised on the third day for patients without infection. At a mean follow-up of 8.5 months, there have been no cases of revision, fracture or stem migration.

Discussion: The rate of total hip arthroplasty revision is an estimated 10%. The risk of an incident during cement ablation is an estimated 18% to 28%. Advantages of the ultrasound technique include: shorter operative time, simple material, less danger for weak bone as noted in our patients, absence of the need for complementary fixation, shorter hospital stay, and lower cost. Histology studies have demonstrated the absence of deleterious effects of ultrasound ablation explaining the good quality of recementing (12 cases).

Conclusion: Ultrasound ablation of femoral cement is effective for aseptic revision. In case of infection, the presence of persistent cement might be related to recurrent infection.

Purpose: Loosening and wear of the polyethylene insert remains an important problem after ten years. The Harris-Galante 1 (HGP1) press fit titanium backed cup appears to provide an interesting alternative. We studied the clinical and radiological outcome of 191 total hip arthroplasties performed between June 1985 and June 1990.

Material and methods: This prospective continuous series included 174 patients (191 hips), 76 women and 98 men, mean age 62.1 years (19–83). The posterior approach was used in all cases for treatment of degenerative hip disease (80%) or osteonecrosis (14.6%). The polyethylene-metal cup was used with a 28mm head in 90.7% of the cases. The press-fit cup was fixed with three screws. At review, 39 patients had died (45 hips), 25 were contacted for a phone interview, and two were lost to follow-up; 119 patients were re-examined and had a standard radiography series at last follow-up. Mean follow-up was 11.9 years (10–15). The Postel Merle d’Aubigné (PMA) score and the Harris hip score (HHS) were used to assess outcome. Quality of bone fixation and cup migration were studied as were lucent lines classed according to De Lee. Wear was calculated using the Livermore method and osteolysis using the Mulroy method. Actuarial survival curves were plotted using reoperation as the end-point if the polyethylene insert was changed or revision if the cup was changed for any reason. Qualitative data were compared using chi square test.

Results: There was one death on day three and three dislocations including two requiring reoperation for an insert overhang. The PMA pain score improved from 2.58 to 5.5 and the overall PMA score from 10.5 to 16.2. the HHS improved from 53.5 to 87.2 points. A lucent line measuring < 1 mm was found in 12 cases; one was complete, nine were in a single zone. Osteolysis was found in 28 cases and was qualified as severe in four. Mean polyethylene wear was 0.1 mm (volume 65.5 mm³). There was no case with cup migration or cup tilt and none of the cups had to be changed. Five polyethylene inserts were changed due to wear at a mean 145 months. The actuarial survival curve taking into account the seven insert changes showed a mean 15-year survival of 96.7±3%.

Discussion: The Harris-Galante press-fit cup has exhibited good behaviour at a mean 11.9 years follow-up. Mean annual wear was = 0.1 mm in 42 patients; it was > 0.2 mm in 18 patients including five who required reoperation to change the insert at 145 months. Osteolysis was noted in 28 cases, an important problem.

Conclusion: With only two patients lost to follow-up at ten years, this prospective review demonstrates well that the press-fit cup is well tolerated which has suffered from comparison with cemented cups. Five worn inserts had to be changed, requiring a simple operation. There were four cases of severe osteolysis.