E. Masmejean

Collagenase clostridium histolyticum in patients with Dupuytren’s contracture: results from POINT X, an open-label study of clinical and patient-reported outcomes

In POINT X, a study designed to reflect clinical practice and patient treatment choices, 254 European patients received open-label collagenase for Dupuytren’s contracture. The most severely affected joint was treated first in 74% of patients. In total, 52%, 41%, 7%, and 1% of patients selected the little, ring, middle, and index finger, respectively; 79% had one or two joints treated. Only 9% of patients (n = 24) received 4 or 5 injections. The mean improvement in total passive extension deficit (TPED) was 34° on day 1, improving further by day 7 to 42°. This secondary improvement was maintained by day 90 and month 6. The mean number of injections/joint was 1.2 for the metacarpophalangeal joint and 1.25 for the proximal interphalangeal joint. Median time to recovery was 4 days; the mean improvement in hand function was clinically relevant as measured by the Unité Rhumatologique des Affections de la Main (URAM) score. In total, 87% and 86% of patients and physicians, respectively, were very satisfied or satisfied with treatment at month 6, although correlation between TPED and patient satisfaction was weak (Spearman −0.18, 95% CI −0.32 to −0.06). Collagenase was well tolerated, with 10 (3.9%) patients experiencing severe adverse events. As a real-world study, the POINT X findings can be generalized to the at-large population.

Fractured coracoid with anterior shoulder dislocation and greater tuberosity fracture: report of a bilateral case

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Mini-invasive surgery for chronic exertional compartment syndrome of the forearm: a new technique.

Chronic exertional compartment syndrome is now easily identified among the athletic population. It remains common in motorcyclists. The only treatment is the fasciotomy of the compartments and the gold standard procedure is still the open-invasive surgery. The authors describe a new mini-invasive surgical procedure to perform a 4-compartment fasciotomy of the forearm, and expose their results. Over a 3-year period, we reviewed 16 cases of forearm compartment fasciotomy for 8 patients with bilateral chronic exertional compartment syndrome of the forearm who had been operated on. All 8 were males, with an average age of 23 years. All were competition motorcyclists, either in cross-country or speed competitions. They were all treated with the same bilateral procedure: a mini-open fasciotomy of the 4 forearm compartments using the Knifelight, which is a sharp blade between 2 plastic blunt skids originally designed for carpal tunnel release. All patients had resumed their sport in the 6 weeks after the surgery. They were back to their previous level in 3 cases, and improved their level in 5 cases. No complications and no recurrences were reported during an average 2-year follow-up. The mini-invasive technique for fasciotomy seems to be as efficient as the open technique procedure, which is still the gold standard. But the length of surgery, recovery time, and scar sequelae are much better. Mini-invasive surgery is simple, efficient, and the results are reproducible.

Brachial Plexus Injuries in Scapulothoracic Dissociation

The rare condition of scapulothoracic dissociation (STD) is characterized by a lateral displacement of the scapula from the thoracic cage following severe trauma to the scapular girdle. This study presents an analysis of five STDs. There were three supraclavicular brachial plexus palsies and two retro- and infraclavicular palsies. Recovery of elbow flexion was obtained in only two cases. Nerve damage dominates the prognosis and nerve recovery only rarely occurs. Nerve surgery should attempt to reestablish elbow flexion

Trauma care systems in France.

The French Republic includes approximatively 60 millions inhabitants for almost 550,000 km(2). Prehospital management is organised at department level (96). This management involves a regulatory system initiated from a unique phone number (15 national). The medical regulator sends either first-aid providers or a medical team. On-site care is highly developed and prehospital medically assisted care is really the first phase of the treatment of the injured. The team ensures that the victim is in the best condition for transport and participates in monitoring. Intra-hospital care begins either in an emergency room, with a physician qualified in Emergency Medicine, or in a recovery room, with a surgical intensive-care team. There is no specialisation in trauma in France. All specialist surgeons treat those aspects of trauma pathology that concern them. All surgeons operate on trauma patients and with regard to the organ concerned: digestive, orthopaedic, em leader. The challenge nevertheless remains that of maintaining facilities at a sufficient level to deal with everyday pathology, known for the seriousness of its consequences in both human and financial terms, within an increasingly sparse hospital infrastructure. Suggestions are emerging in response to these preoccupations. Organisation at the European level of hand emergency units (FESUM) is a targeted example.

Results of non-operative and operative treatment of humeral shaft fractures A series of 104 cases

The aim of this study was to examine the results of different modalities applied in the treatment of 104 fresh diaphyseal fractures of the adult humerus treated in the department between January 1994 and March 1997. These results were classified according to the criteria described by Stewart and Hundley. 32 patients (30.8%) were treated non-operatively using a sling and a moulded plaster splint. The type of treatment had to be changed in 12 of these patients due to 14 different complications that occurred during the course of non-operative treatment. Thus, 20 patients (62.5%) underwent non-operative treatment until fracture-union. The results in this group were: very good in 12 cases (60%), good in 5 cases (25%), fair in 3 cases (15%). 28 fractures were treated using plates and screws. 4 events (14%) occurred during in the post-operative period and, apart from 2 cases of non-union, the overall result in the 26 patients in whom the fracture united was: very good in 23 cases (88.5%) and good in 3 cases (11.5%). 22 patients (21.1%) underwent fixation using multiple flexible intramedullary wires via a supracondylar approach. Apart from one case of non-union, the final result in the 21 patients in whom the fracture united was: very good in 9 cases (42.8%), good in 9 cases (42.8%), fair in 2 cases (9.5%) and poor in 1 case (4.9%). 22 fractures were treated using an intramedullary Seidel nail. The final result in these patients was: very good in 11 cases (50%), good in 9 cases (41%) and poor in 2 cases (9%). The indications for treatment should be eclectic. Non-operative treatment remains the method of choice for undisplaced or minimally-displaced fractures or comminuted fractures with multiple parallel longitudinal fracture-lines over the middle-third, while surgical treatment is considered for displaced fractures and essentially depends upon the type and level of the fracture. Transverse and short oblique fractures are treated using a plate or a Seidel nail. Fractures with a third fragment require plate osteosynthesis. Multiple flexible intramedullary wires are used for segmental fractures or for diaphyseal fractures associated with fractures of the neck of the humerus. Comminuted fractures are realigned using an intramedullary Seidel nail or multiple flexible wires. As far as the site of fracture is concerned, those of the proximal and middle thirds of the humerus are well treated using an intramedullary nail or multiple wires or with a plate, while plating is most often the method of choice for fractures of the distal-third.

Palmar Perilunate Fracture-Dislocation of the Carpus

We report an uncommon palmar translunate, transhamate carpal fracture dislocation. CT-scans with three-dimensional reconstruction were most helpful for the assessment of the injury, which was treated operatively through a palmar approach. The lunate and hamate fractures were fixed using mini-screws and the radial styloid fracture and the scaphoid were reduced and stabilized with K-wires.

Terrorist attacks in Paris: Surgical trauma experience in a referral center

BACKGROUND On November 13th, 2015, terrorist bomb explosions and gunshots occurred in Paris, France, with 129 people immediately killed, and more than 300 being injured. This article describes the staff organization, surgical management, and patterns of injuries in casualties who were referred to the Teaching European Hospital Georges Pompidou. METHODS This study is a retrospective analysis of the pre-hospital response and the in-hospital response in our referral trauma center. Data for patient flow, resource use, patterns of injuries and outcomes were obtained by the review of electronic hospital records. RESULTS Forty-one patients were referred to our center, and 22 requiring surgery were hospitalized for>24h. From November 14th at 0:41 A.M. to November 15th at 1:10 A.M., 23 surgical interventions were performed on 22 casualties. Gunshot injuries and/or shrapnel wounds were found in 45%, fractures in 45%, head trauma in 4.5%, and abdominal injuries in 14%. Soft-tissue and musculoskeletal injuries predominated in 77% of cases, peripheral nerve injury was identified in 30%. The mortality rate was 0% at last follow up. CONCLUSION Rapid staff and logistical response, immediate access to operating rooms, and multidisciplinary surgical care delivery led to excellent short-term outcomes, with no in-hospital death and only one patient being still hospitalized 45days after the initial event.

Reduction of neural scarring after peripheral nerve suture: An experimental study about collagen membrane and autologous vein wrapping

The effects of a collagen membrane and a technique of autologous vein wrapping on scar formation after peripheral nerve suture are investigated. Forty-eight sciatic nerves from Wistar rats were transected and repaired, then allocated to a control group C (n=16) and two experimental groups: in group A (n=16) the repair line was covered by the collagen membrane, and in group B (n=16) the repair line was wrapped by an external jugular venous graft. Three months later, it was observed that adhesions in the surrounding tissues were significantly less in groups A and B compared to group C, and significantly less in group A than in the group B. Histological analysis revealed no significant reduction of extraneural or intraneural scar tissue in groups A or B compared to group C. However intraneural fibrosis was significantly less in the group A than in the group B. It was concluded that the collagen membrane was effective in reducing neural scar formation after peripheral nerve suture. Autologous vein wrapping also showed a favorable effect in this indication despite less successful histological outcomes.

Surgical replacement of the thumb saddle joint with the GUEPAR prosthesis

ZusammenfassungIn der chirurgischen Behandlung der Daumensattelgelenksarthrose stellt die prothetische Versorgung eine Möglichkeit im chirurgischen Armentarium dar. Eine der vielen Möglichkeiten der prothetischen Versorgung repräsentiert dabei die GUEPAR-Prothese, die 1982 entwickelt wurde.Die GUEPAR-Prothese besteht aus einer Metall-Polyethylen-Verbindung und ist in 4 Schaftgrößen erhältlich. Die Indikation zur prothetischen Versorgung bei der Rhizarthrose wird beim eher älteren Patienten gestellt, der an einer schmerzhaften, fortgeschrittenen Rizarthrose (Stadium 3 oder 4 nach Dell) bei erhaltener Höhe des Trapezium leidet. Kontraindikationen stellen jüngere Patienten dar, die ihre Hände manuell stark belasten. Ebenso müssen Patienten von der prothetischen Versorgung ausgeschlossen werden, die ein zu kleines Trapezium aufweisen.Die Autoren berichten über die 51 ersten Fälle der GUEPAR-Prothese, die zwischen 1995 und 1999 implantiert wurden.Die durchschnittliche Beobachtungszeit beträgt 27 Monate. Die klinischen Resultate wurden in allen Fällen als exzellent oder gut beurteilt. Radiologisch fanden sich bei 46 Prothesen keinerlei Veränderung. Bei 4 Prothesen konnten Lockerungszeichen beobachtet werden, 2-mal am Trapezium und 2- mal bei beiden Komponenten. Diese Lockerungszeichen hatten aber keine Konsequenzen auf das klinische Resultat. In einem Fall kam es zu einem Einsinken der metacarpalen Komponente, ebenfalls ohne klinische Symptome. Es wurde keine Luxation beobachtet, ebenso mussten keine Patienten reoperiert werden.Die klinischen Resultate zeigen, dass neben der guten Schmerzbefreiung durch die Daumensattelgelenksprothese die Länge des Daumenstrahls erhalten werden kann und so die Opposition und die Greifmöglichkeit zu den Langfingern des Daumens verglichen zur Trapezektomie verbessert sind. Des Weiteren war die gesamte Rehabilitationszeit in der Gruppe der Prothesenpatienten deutlich kürzer als nach Trapezektomien. Radiologisch scheint die anatomisch korrekte Form des Metakarpaleprothesenschafts die korrekte Positionierung der Prothese auch längerfristig zu garantieren.AbstractPrimary arthritis of the thumb saddle joint is very common. Among the different treatment options, the implantation of a total joint arthroplasty is an alternative. The GUEPAR prosthesis, developed by a group of French surgeons, is mainly used in elderly patients and only in cases with preserved trapezial height.This study reports the mid-term results of the second generation of this implant. The clinical results show good pain relief and good mobility of the thumb. There were a few patients with radiological signs of implant loosening, but none of them had clinical problems. The advantage of a total replacement of the saddle joint, compared to the standard resection arthroplasty, is faster rehabilitation and preservation of the length of the thumb.The new generation of the GUEPAR prosthesis has a more anatomical metacarpal stem and a modularity which allows the fit of the implants according to the anatomical situation.