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Rupture of the brachial artery associated with radial nerve palsy in a context of exostosis of the proximal humerus has not been described to date in the literature. Our patient was a fourteen-year-old girl with a history of violent pain occurring suddenly with no prodrome or triggering factor. The pain was localized at the level of the proximal left humerus. Physical examination revealed the presence of a hematoma and complete motor radial nerve palsy. The diagnosis was not confirmed by computed tomography with contrast injection but was confirmed by magnetic resonance imaging which eliminated malignant transformation of the exostosis. After checking the neurovascular bundles and evacuating the hematoma, treatment consisted in resection of the exostosis and arterial repair with an autologous venous graft. We discuss the diagnostic and therapeutic challenges which present vascular complications due to exostosis.

Current indications for high tibial osteotomy (HTO) are controversial although several risk factors have been associated with HTO survival. We ascertained the influence of preoperative variables in a consecutive series of patients who had closing wedge HTO at a minimum of 12 year followup (mean 18-year, range 12 to 28 years). Three hundred one of an initial 372 high tibial osteotomies (313 patients) were included (81% followup); 71 knees were eliminated because patients died (30 knees) or were lost to followup (41 knees). The mean age was 42 years (range, 15-76 years), 194 were men and 119 were women. The osteotomy was fixed by a Blount staple and an AO half-tube plate with three screws. Forty-three knees (14%) in 39 patients were revised for progression of osteoarthritis at an average of 102 months. Survival was 85% at 20 years with revision as the endpoint. Knee function was considered satisfactory by 77% of patients. At final followup, 1/2 of the knees showed radiographic signs of medial osteoarthritis. The most important risk factors predicting revision were age greater than 50 years and a preoperative arthritis Ahlback grade of 3 or more.

Unicompartmental knee arthroplasty is an alternative to total knee arthroplasty for patients with unicompartmental tibiofemoral noninflammatory disease. Careful patient selection and newer instrumentation has reduced the progression of arthrosis in the other compartment and tibial loosening, leaving polyethylene wear as the predominant failure mechanism in more contemporary designs. Increased wear increases the debris volume at the bone-implant interface, and wear particles will generate osteolysis leading to component loosening and unreplaced compartment degeneration. The design-related factors that minimize wear include a polyethylene thickness of greater than 6 mm, a limited shelf age, and a design allowing large areas of contact mediolaterally and anteroposteriorly. Congruous mobile-bearing implants could play a substantial role in reducing wear if they are not associated with dislocation and nonreproducible surgical techniques. Important technical factors include accurate instrumentation avoiding component-to-component malposition and edge loading, allowing slight under-correction of the pre- operative deformity. The patient-related factors include a weight limit, a functional anterior cruciate ligament, and a correctable frontal deformity. Continued research including that related to cross-linking and sterilization methods is mandatory to improve polyethylene strength. A better understanding of kinematics and contact forces may provide long-term survival and patient satisfaction after unicompartmental arthroplasty.

Purpose of the Study: Intra-focal pinning as described by Kapandji in 1976 is generally standard treatment of fractures of the distal radius with posterior displacement. This technique, based on the bench effect of pinning on the posterior and radial cortexes has certain limitations in the event of major posterior comminution. In order to improve stability, other authors have proposed a modification of the Kapandji technique, replacing the lateral intra-focal pin with a direct trans-styloid pin. The purpose of this prospective radiographic study was to determine whether the modified Kapandji method improves the quality of postoperative reduction and provides a gain in stability., Material and Methods: This prospective radiographic study included 85 patients. The first group, composed of 41 patients, was treated with the standard intra-focal pinning using one or two dorsal pins and one lateral pin (group K). The second group of 44 patients was treated with one or two intra-focal pins and one lateral transfocal pin (group KM). The postoperative care was the same for the two groups. Clinical and radiographic assessment (lateral and AP views) was performed at day 21, at day 45 after removal of the pins, and at last follow-up. Two operators working independently from the surgeons measured the orientation of the radial surface on the lateral and AP views and the radioulnar variance at day 0, 21, 45 and last follow-up., Results: Group K included 38 patients, mean age 57 years, and group KM 40 patients, mean age 53 years. Seven patients were lost to follow-up. The two groups were comparable regarding age, gender, type of lesion. The postoperative assessment showed radial inclination of 19.3 degrees on the AP view and 3 degrees on the lateral view with 6.6 degrees radiolulnar variance for the K group. The corresponding values were 22.2 degrees , 5.3 degrees and 12.2 degrees for the KM group. Postoperatively, there was a significant difference between the groups for radial glenoid on the AP view (p=0.004) and radiolulnar variance (p<0.0001) but there were no differences on the lateral view. At day 45 postop, mean values were 17.3 degrees AP and 1.1 degrees lateral for radial inclination and 2.2 degrees for radioulnar variance in the K group with 21 degrees , 4.7 degrees and 10 degrees in the KM group. There was a difference in group K for values measured on day 0 and day 45. There was no significant difference between the values on day 0 and day 45 for the KM group., Discussion and Conclusion: The purpose of this radiological assessment was to evaluate the efficacy of replacing the lateral intra-focal pin with a lateral transfocal pin in terms of primary stability of extra-articular fractures of the distal radius with posterior displacement. The results appear to show that this technique provides more sustained reduction during the first six weeks, particularly concerning radioulnar variance and radial glenoid inclination on the AP view, objectives needed for good clinical outcome. It also enables a notable improvement in postoperative stability while preserving the advantages of an easily reproducible minimally destructive percutaneous technique.

Purpose of the Study: Arthroplasty in developmental dysplasia of the hip joint raises technical problems related to the anatomy and age of the young patient. The purpose of this work was to report results obtained with a custom-designed cementless stem., Material and Methods: This study included 257 hips reviewed at mean 82 months (range 43-162 months). Mean patient age was 55 years (17-78), mean weight 67 kg (42-118), and mean height 164 cm (147-190). A standard imaging protocol was performed for all patients: AP pelvis in reclining position, AP and lateral views of healthy and pathological hip, AP view of entire lower limb in standing position, computed tomography of lower limb. La position of the greater trochanter and the lengthening necessary was determined from the preoperative films. Stem integration and migration as well as osteolysis were studied postoperatively. Femoral anteversion and the anteroposterior diameter of the paleoacetabulum were measured on the superposed computed tomographic images. Surgery was performed via a Watson-Jones approach to insert a noncemented cup hooked in the obturator foramen and implanted in the paleoacetabulum. The femur endomedullary cavity was prepared with a ream having the form of the definitive stem and the prosthetic neck was custom fit to match the desired lever arm and anteversion., Results: The series included 174 cases of dysplasia and 83 dislocations, 39% stage 1, 30% stage 2, 14% stage 3 and 17% stage 4. Mean lengthening was 39 mm. The mean helitorsion was 28 +/- 16 degrees and the mean anteroposterior diameter of the acetabulum was 51 mm. On average, the alpha correction in the prosthetic neck was -13.4 degrees (-71 degrees to +37 degrees). The Postel-Merle-d'Aubigné score improved from 10.4 points preoperatively to 16.7 points at last follow-up. Postoperative x-rays showed signs of osteointegration in 88% of cases, osteolysis in 5% and one case of stem impaction. Ten hips (3.9%) required revision for replacement (7 for an aseptic problem and 3 for sepsis). Survival was 94.7% at 13 years., Discussion: This study confirmed the anatomic modifications observed in patients with developmental hip dysplasia and the surgical problems they cause. There was no correlation between the degree of dislocation and the degree of helitorsion which is difficult to assess without a preoperative computed tomography. The survival rate at 13 years is encouraging in this population. The intramedullary portion of the cementless stem must be adapted to the dimensions of the femoral canal which decrease with increasing dislocation.

Unlabelled: The rationale for presenting this updated study is to report long-term clinical and survival results of patellofemoral arthroplasty and to ascertain whether the preoperative diagnosis influenced outcomes and therefore indications. We retrospectively updated a previous evaluation of 66 patients who had unilateral patellofemoral arthroplasty between 1972 and 1990. The mean age of the patients at the initial surgery was 57 years (range, 21-82 years). The patients had an average followup of 16.2 years (range, 12-20 years). Preoperative diagnosis included instability, fracture, and primary arthritis. Revision surgery was done in 14 patients for femorotibial osteoarthritis, in 11 for loosening, and in four for stiffness. Survivorship was 58% at 16 years. The knee function score improved from 40 points preoperatively to 81 points at last followup. The best results were in patients with preoperative instability and corrected alignment of the extensor mechanism. Stiffness occurred only in those patients with osteoarthritis from previous fracture. Progressive degeneration of the tibiofemoral joint was noted mainly in the primary osteoarthritis etiologic group. This long-term evaluation of patellofemoral arthroplasty showed the importance of patient selection while excluding knees with significant frontal tibiofemoral malalignment., Level of Evidence: Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.