Didier Ollat

Interest of an intraoperative limb-length and offset measurement device in total hip arthroplasty

INTRODUCTION Total hip arthroplasty (THA) seeks to restore a stable, mobile and pain-free joint. This requires good implant positioning and peroperative restoration of limb-length and femoral offset. HYPOTHESIS A mechanical measurement device (length and offset optimization device [LOOD]) fixed to the pelvis can optimize lower-limb length and offset control during THA performed on a posterolateral approach. PATIENTS AND METHODS Two prospective THA series were compared: 32 using the LOOD and 26 without. Patients with more than 5mm preoperative limb-length discrepancy were excluded. The intraoperative target was to restore individual anatomy. Radiographic analysis was based on pre- and postoperative AP pelvic weight-bearing views in upright posture, feet aligned, with comparison to peroperative LOOD data. RESULTS Mean deviation from target length (i.e., pre- to postoperative length differential) was 2.31 mm (range, 0.04-10.6mm) in patients operated on using the LOOD versus 6.96 mm (0.01-178 mm) without LOOD (P=0.0013). Mean deviation from target offset was 3.96 (0.45-13.50) mm with LOOD versus 10.16 (0.93-28.81) without (P=0.0199). There was no significant difference between operative and radiographic measurements of length deviation using LOOD (P=0.4); those for offset, however, differed significantly (P=0.02). DISCUSSION The LOOD guides control of limb-length and offset during THA on a posterolateral approach. Reliability seems to be better for limb-length than for offset. It is a simple and undemanding means of controlling limb-length and offset during THA. LEVEL OF EVIDENCE III, prospective case-control study.

French surgical experience in the role 3 medical treatment facility of KaIA (Kabul International Airport, Afghanistan): the place of the orthopedic surgery.

INTRODUCTION In 2009, the French took command of the Medical Hospital (MH) or Role 3 Hospital at KaIA (Kabul International Airport) within the framework of its role in the military mission Operation Pamir in Afghanistan. The goal of this study was to analyze the volume of orthopedic surgical activity for the last four years, to identify its specificities and to improve training of military orthopedic surgeons. HYPOTHESIS Orthopedic surgery is the most important activity in the field and surgeons must adapt to situations and injuries that are different from those encountered in France. PATIENTS AND METHODS All patients operated on between July 2009 and June 2013 were prospectively included in an electronic database. The analysis included the number of surgical acts and patients, the types of injuries and the surgical procedures. RESULTS Forty-three percent (n=1875) of 4318 procedures involved orthopedic surgery. Half of these were emergencies. French military personnel represented 17% of the patients, local civilians 47% and children 17%. Half of the procedures involved the soft tissues, 20% were for bone fixation and 10% for surgery of the hand. The rate of amputation was 6%. The diversity of the surgical acts was high ranging from emergency surgery to surgical reconstruction. DISCUSSION The activity of this Role 3 facility is comparable to that of other Role 3 facilities in Afghanistan, with an important percentage of acts involving medical assistance to the local population and scheduled surgeries as well as primary and/or secondary management of the wounded. The diversity of surgical acts confirms the challenge of training military orthopedic surgeons within the context of the hyperspecialization of the civilian sector. Specific training has been organized in France by the École du Val de Grâce. Specific continuing education is also necessary. LEVEL OF EVIDENCE IV (retrospective review).

Outcomes of talar dome osteochondral defect repair using osteocartilaginous autografts: 37 cases of Mosaicplasty®

BACKGROUND The indications of osteochondral autograft implantation using the Mosaicplasty(®) technique were only recently extended to osteochondral lesions of the talus (OLT), a site for which no medium- or long-term outcome data are available. Our objective here was to evaluate medium-term outcomes in case-series of patients who underwent Mosaicplasty(®) for OLT repair. HYPOTHESIS Mosaicplasty(®) provides good medium-term outcomes with low morbidity when used for OLT repair. PATIENTS ET METHODS We retrospectively reviewed cases of Mosaicplasty(®) for OLT repair, performed in combination with malleolar osteotomy on the side of the OLT, at either of two centres, between 1997 and 2013. Pre-operative clinical data were collected from the medical records and all patients were re-evaluated. We studied 37 patients with a mean age of 33 years. RESULTS Mean follow-up at re-evaluation was 76 months. Mean AOFAS score at re-evaluation was 83 (range, 9-100). A work-related cause to the OLT was associated with significantly poorer outcomes (P=0.01). AOFAS values were significantly better in patients whose OLT size was 0.5 to 1cm(2). The Ogilvie-Harris score at last follow-up was good or excellent in 78% of patients. No patient experienced morbidity related to the malleolar osteotomy. Persistent patellar syndrome was noted in 6 patients. DISCUSSION In our case-series, Mosaicplasty(®) for OLT repair provided good medium-term outcomes in 78% of patients. Nevertheless, the donor-site morbidity should be borne in mind. Mosaicplasty(®) deserves to be viewed as a reference standard method for OLT repair. LEVEL OF EVIDENCE IV, retrospective study.

Wartime upper extremity injuries: experience from the Kabul International Airport combat support hospital.

Few epidemiologic studies have been published about the surgical management of wartime upper extremity injuries (UEIs). The purpose of the present report was to analyze upper extremity combat-related injuries (CRIs) and non-combat related injuries (NCRIs) treated in the Kabul International Airport Combat Support Hospital. A retrospective study was conducted using the French surgical database OpEX (French military health service) from June 2009 to January 2013. During this period, 491 patients with a mean age of 28.7 ± 13 years were operated on because of an UEI. Among them, 244 (49.7%) sustained CRIs and 247 (50.3%) sustained NCRIs. A total number of 558 UEIs were analyzed. Multiple UEIs and associated injuries were significantly more common in the CRIs group. Debridement was the most common procedure in both groups. External fixator application, delayed primary closure and flap coverage were predominant in the CRIs group, as well as internal fracture fixation and tendon repair in the NCRIs group. The overall number of surgical episodes was significantly higher in the CRIs group. Due to the high frequency of UEIs in the theatres of operations, deployed orthopedic surgeons should be trained in basic hand surgery. Although the principles of CRIs treatment are well established, management of hand NCRIs remains controversial in this setting.

Disjonctions acromio-claviculaires traitées par ligamentoplastie synthétique coraco-claviculaire: Révision de 75 cas à 7,5 ans de recul moyen

PURPOSE OF THE STUDY The aim of this study was to evaluate results of coraco-clavicular ligamentoplasty using a synthetic material, dacrylene, for the treatment of recent and neglected acromio-clavicular dislocation. MATERIAL AND METHODS The series initially included 104 patients who underwent surgery from 1981 to 2001. Among these, 75 were reviewed with a mean follow-up of 85 months (72% review rate). A complete set of clinical (Constant score/100 points) and radiographic (coraco-clavicular distance) data was available for 39 patients. Thirty-six answered a questionnaire with measurement of a partial Constant score (65 points). RESULTS Seventy-seven percent of patients were satisfied or very satisfied and 98% presented good or very good functional outcome as assessed by the partial Constant score. Reduction of the coraco-clavicular distance was satisfactory for 54% of patients evaluated. For the vast majority, insufficient reduction was reducible and had no impact on the functional outcome. The time to treatment (recent or neglected dislocation) had no effect on patient satisfaction or functional outcome. The coraco-clavicular distance was greater for dislocations operated on late (p<0.05). The grade of the injury, the type of assembly used, and use or not of lateral clavicular resection had no effect on clinical or radiological outcomes. Dacrylene was tolerated poorly by 14 patients (18.7%). The functional outcome was very good for all after removal of the ligament. DISCUSSION Functional results are good with this technique which enables a well sustained stable reduction of recent and neglected dislocations, irrespective of the grade of the lesion or the type of assembly used. Reducing the mechanical stress on the ligament and prudent rehabilitation exercises should be helpful in preventing intolerance reactions.

How to Cover Soft-Tissue Defects After Injuries to the Leg in Precarious Conditions

Background:In precarious conditions, bone exposure on the leg is synonymous with amputation. The authors describe their experiences with such injuries in 15 patients.Materials and methods:Fifteen patients were operated by the same surgeon in Afghanistan and Ivory Coast for bone exposure on the leg after war or roadcrash injuries. A flap was performed after an initial debridement and external fixation. The delay between the flap and the first injury was about 42 days.Results:The duration of hospitalization following the flap was about eight days. Cicatrization was complete after 25 days. Three patients had complications: one partial necrosis of the skin, one sepsis, and one patient had a leg amputation.Discussion:In precarious conditions, the management of bone exposure in local civilians and soldiers is limited by the conditions in their country or the conditions at the field hospital. The treatment must be simple and reliable because it may be difficult to perform patient follow-up. A pedicled flap provides new vascularized tissue with anti-infectious properties. Classical indications are: muscular flaps for the proximal and the middle part of the leg; sural flaps for the middle and the distal-third part. In substantial soft-tissue defects, amputation must be discussed.Conclusion:The pedicled flap is an essential technique for fighting against infection, especially in cases where only poor technical and medicinal resources are available. This simple and reliable technique allows most tissue defects on the leg to be covered.

Is the Segond’s fracture a reliable sign of anterior cruciate ligament (ACL) tear? A case report without associated ACL rupture

Segond’s fracture is an avulsion fracture of the lateral rim of the tibial plateau. It is described as a “capsular sign” of associated anterior cruciate ligament (ACL) tears. The clinical examination of a traumatically painful knee is often difficult. For this reason the Segond’s fracture is considered a helpful sign for the diagnosis of ACL ruptures. We report an uncommon case of an isolated Segond’s fracture without ACL rupture (or other internal derangement) associated. With this report we have reviewed literature to know the real occurrence of the Segond’s fracture with ACL tears. The question to be answered is if this lesion really is a sign of association of ACL tears. Most of the cases published are isolated and only one paper has analyzed this occurrence precisely. The scientific literature concludes that the Segond’s fracture is a strong indirect sign of ACL’s tear associated in injured knee.

Surgical support during the terrorist attacks in Paris, November 13, 2015: Experience at Bégin Military Teaching Hospital.

BACKGROUND Recent conflicts have allowed the French Army Health Service to improve management quality for wartime-injured people during military operations. On November 13, 2015, it was in Paris that France was directly attacked and Bégin Military Teaching Hospital, like several hospitals in Paris, had to face a large number of gunshot victims. Thanks to our operational experience, injured people hospitalized in military hospitals benefited from a management based on triage and damage control (DC) principles. METHODS Forty-five patients were taken care of in our hospital with an average age of 32 years. During triage, eight patients were categorized T1 (with four extreme emergencies) and 10 were classified T2 and 27 as T3. Twenty-two patients underwent emergency surgery, 15 for soft tissue lesions of limbs, 8 for ballistic fractures (one of which was a cervical wound), and 5 for abdominal wounds. Two patients classified T1 died early. RESULTS In total, more than 50 operations were performed including iterative debridements, bone fixation, three amputations, and two flaps. After 9 months, all of the patients had healed. One woman with limb stiffness required an arthrolysis. CONCLUSION This event showed that terrorist attacks and mass casualties with war wounds can occur in France. Acquired experience regarding war wounds by the French Army Health Service is precious. Everyone must understand the importance of triage and the principles of damage control. Every hospital must be ready to face this type of massive influx of injured people (white plan). LEVEL OF EVIDENCE Epidemiological study, level V.

Initial management of complex hand injuries in military or austere environments: how to defer and prepare for definitive repair?

IntroductionThe damage control orthopedics (DCO) concept is a sequential surgical management strategy indicated when ideal primary treatment is not possible or suitable. DCO principles are routinely applied to hand traumas in wartime practice, but could also be useful in a civilian setting when immediate specialized management cannot be carried out.MethodsThe authors report three typical observations of soldiers treated for a complex hand trauma on the field by orthopedic surgeons from the French Military Health Service (FMHS). Application of the hand DCO concept is analyzed and discussed considering the literature and the FMHS experience.ResultsWith regards to treating the hand, DCO necessitates a meticulous debridement with precise wound assessment, the frequent use of a primary definitive internal fixation by K-wires, and the possibility of a temporary coverage. These simple and fast procedures help avoid infection and prepare the hand for secondary repair.ConclusionHand DCO can be applied by any surgeon in various situations: in association with polytrauma, complex injuries requiring multiple reconstructions, or delayed transfer to a specialized center.

Fracture des deux os de l'avant-bras sur synostose radio-ulnaire congénitale : À propos d'un cas

Resume Nous rapportons le cas d’une fracture diaphysaire des deux os de l’avant-bras survenue chez un patient de 18 ans presentant une synostose radio-ulnaire congenitale. Le mecanisme traumatique etait mixte, associant un choc direct et une supination forcee sur un cadre antebrachial bloque a 30° de pronation. L’osteosynthese a ete realisee en urgence de facon classique, sans chercher a modifier la position d’ankylose. La synostose radio-ulnaire congenitale semble entrainer une vulnerabilite particuliere du cadre antebrachial aux contraintes en torsion. Ceci doit etre pris en compte lors de la pratique de sports de contact sollicitant les mouvements de prono-supination.We report a case of shaft fracture involving both forearm bones in an 18-year-old male presenting congenital radioulnar synostosis. The mechanism of fracture involved both direct blunt trauma and forced supination on forearm frame blocked in 30 degrees pronation. Emergency osteosynthesis was performed using a standard procedure without any attempt to modify the ankylosis position. Congenital radioulnar synostosis appears to produce a rather vulnerable forearm due to restrained torsion. This notion must be taken into account in such subjects participating in contact sports which solicit pronation-supination.