G. Versier

Knee MR-arthrography in assessment of meniscal and chondral lesions

INTRODUCTION No study, so far in France, has investigated the diagnosis value of knee MR-arthrography since the recent approval of intra-articular gadolinium use, by this countrys healthcare authorities. This study objective is to verify the MR-arthrography superiority on conventional knee MRI, in meniscus and cartilage knee lesions diagnosing accuracy both in regard to sensitivity and specificity. HYPOTHESIS MR-arthrography, represents in some pathologic situations, a more accurate source of information than conventional MRI. MATERIALS AND METHODS Over a 27 months period, 25 patients, scheduled to undergo a knee arthroscopy volunteered, after having been fully informed of the possible interest and risk of the MR-arthrography examination, to participate in this study. Twenty-one of them were finally included since in four cases the surgical indication was not confirmed. The group consisted of 15 males and six females with an average age of 35.7 years. All of them consecutively underwent conventional MRI, MR-arthrography finally followed by arthroscopy. The MRI and MR-arthrograms results were compared to the arthroscopy findings using the nonparametric Kappa test. RESULTS To diagnose meniscal tears, statistical agreement measure for MRI with arthroscopy was good (K=0.69) but not as good as the MR-arthrography/arthroscopy agreement which, by itself was excellent (K=0.84). As a diagnosis tool, the sensitivity and specificity of MR-arthrography (respectively 100 and 89.6%) were much higher than the corresponding values observed in conventional MRI (92.3 and 82.8%, respectively) which nonetheless remain satisfactory. The meniscal tears characterization seemed to be better interpreted using MR-arthrography. As far as the chondral lesions in this series, they were predominantly located on the patellar surface and in the medial femorotibial compartment. For diagnosing the latter, the MRI/arthroscopy agreement was good (K=0.70) but not as good as the MR-arthrography/arthroscopy agreement (K=0.805) which can be rated excellent. The detection sensitivity thus increased by 10% with gadolinium intra-articular injection. However, assessment accuracy of the lesions depth was mediocre, with frequent errors for the intermediary stages. DISCUSSION Intra-articular gadolinium injection improved MRI performances for numerous reasons: filling the joint, reinforcing the synovial fluid signal, and enhancing anatomic structures contrast on the T1-weighted sequences images. In this study, MR-arthrography appeared to be superior to conventional MRI in meniscal and cartilaginous lesions diagnosis, confirming the results previously obtained in other countries. In light of these results and other data from the literature, MR-arthrography can be indicated as an alternative to CT-arthrography in various clinical situations: detection of recurrent tears on operated menisci, search for cartilaginous lesions or foreign bodies in the joint space, and preoperative assessment before chondral repair procedures. However, conventional MRI remains the reference examination for studying cartilage, because the low resolution of MR-arthrography limits its performances in quantitative assessment of lesions depth.

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 paediatric extremity injuries: experience from the Kabul International Airport Combat support hospital

Since the beginning of Operation Enduring Freedom, management of Afghan military or civilian casualties including children is a priority of the battlefield medical support. The aim of this study is to describe the features of paediatric wartime extremities injuries and to analyse their management in the Kabul International Airport Combat Support Hospital. A retrospective review was carried out using the French surgical database OPEX (Service de Santé des Armées) from June 2009 to January 2013. Paediatric patients were defined as those younger than 16 years old. Of the 220 injured children operated on, 155 (70%) sustained an extremity injury and were included. The mean age of the children was 9.1±3.8 years. Among these children, 77 sustained combat-related injuries (CRIs) and 78 sustained noncombat-related injuries (NCRIs), with a total of 212 extremities injuries analysed. All CRIs were open injuries, whereas NCRIs were dominated by blunt injuries. Multiple extremities injuries and associated injuries were significantly more frequent in children with CRIs, whose median Injury Severity Score was higher than those with NCRIs. Debridement and irrigation was significantly predominant in the CRIs group, as well as internal fracture fixation in the NCRIs group. There were four deaths, yielding a global mortality rate of 2.6%. This study is the first to analyse specifically paediatric extremities trauma and their management at level 3 of battlefield medical facilities in recent conflicts. Except for severe burns and polytrauma, treatment of paediatric extremities injuries can be readily performed in Combat Support Hospitals by orthopaedic surgeons trained in paediatric trauma.

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.

Vacuum-assisted closure: a low-cost negative pressure system for wound management

Negative pressure dressings are helpful for humanitarian surgery for healing infected and late-treated large wounds and also wounds with large loss of skin. However, specific commercial device has high costs that are prohibitive for precarious surgery with limited funds and an austere environment. Our idea is to make a negative pressure dressing using only low-cost and non-specific surgical devices. We describe a technical device of negative pressure in which only low-cost disposable medical equipments were used. The vacuum comes from a surgical room electric pump or from a single-use suction canister. Our successful experience suggests that this low-cost alternative method of negative pressure dressing can be safely used in countries with limited health care systems.

L’abord du subscapularis dans les butées coracoïdiennes. Étude rétrospective de 70 cas

Resume Objectifs. – Exposer les resultats a 2 ans des butees coracoidiennes sur une serie de 70 patients operes entre 1995 et 1998 : section en L-inverse, 31 cas et discision du subscapularis, 39 cas. Methodes. – La force du subscapularis a ete mesuree et une tomodensitometrie a permis la recherche d’une degenerescence graisseuse au sein de ce muscle ainsi que l’etude de la position et l’etat de la butee. Resultats. – Aucun patient ne presente d’instabilite. Le resultat est excellent ou bon dans 92,5 % des cas. Huit pour cent des patients sont mecontents, principalement a cause des complications. L’arthrose est correlee a la position de la butee. Les butees tres basses n’entrainent pas d’apprehension. Dans le groupe des patients operes par section du subscapularis, on note 25 % de degenerescence graisseuse qui altere significativement la force du subscapularis. Conclusions. – La modification d’activite sportive est en partie liee a une apprehension confirmee cliniquement ; ceci n’handicape pas le patient dans la mesure ou il ne fait plus d’episodes d’instabilite et qu’il a modifie son geste technique. Cette intervention entraine une morbidite qui n’affecte pas le resultat subjectif.