Jérôme Pierrart

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.

Terrible triad of the elbow: treatment protocol and outcome in a series of eighteen cases.

The terrible triad is an uncommon injury, which includes an elbow posterior dislocation with fractures of the radial head and coronoid process of the ulna. In addition there is rupture of the lateral and medial collateral ligaments. The short-term and long term results are historically poor, with a high rate of complications. The main objective of this study is to report the results of a multicentre study of patients who sustained the terrible triad injury focusing on surgical treatment in order to offer a standardized surgical protocol. We retrospectively review the results of surgical treatment of eighteen terrible triads from a multicentre study of 226 elbow dislocations. At an average follow up of 31.5 months postoperatively, all eighteen patients returned for clinical examination, functional evaluation, and radiographs. The mean MEPS score value was 78 (25-100), which correspond to three excellent results, ten good results, three fair results, and two poor results. Five early and three late complications were reported. This particular case of elbow dislocation is very unstable and leads to many complications. The surgeon should attempt to restore stability by preserving the radial head whenever possible or replacing it with prosthesis otherwise, by repairing the lateral collateral ligament and performing fixation of the coronoid fracture. If after anatomical restoration of stability elements, the elbow remains unstable, options include repair of the medial collateral ligament or stabilization assumed by hinged external fixator.

Dynamic Three-Dimensional Shoulder Mri during Active Motion for Investigation of Rotator Cuff Diseases.

Background MRI is the standard methodology in diagnosis of rotator cuff diseases. However, many patients continue to have pain despite treatment, and MRI of a static unloaded shoulder seems insufficient for best diagnosis and treatment. This study evaluated if Dynamic MRI provides novel kinematic data that can be used to improve the understanding, diagnosis and best treatment of rotator cuff diseases. Methods Dynamic MRI provided real-time 3D image series and was used to measure changes in the width of subacromial space, superior-inferior translation and anterior-posterior translation of the humeral head relative to the glenoid during active abduction. These measures were investigated for consistency with the rotator cuff diseases classifications from standard MRI. Results The study included: 4 shoulders with massive rotator cuff tears, 5 shoulders with an isolated full-thickness supraspinatus tear, 5 shoulders with tendinopathy and 6 normal shoulders. A change in the width of subacromial space greater than 4mm differentiated between rotator cuff diseases with tendon tears (massive cuff tears and supraspinatus tear) and without tears (tendinopathy) (p = 0.012). The range of the superior-inferior translation was higher in the massive cuff tears group (6.4mm) than in normals (3.4mm) (p = 0.02). The range of the anterior-posterior translation was higher in the massive cuff tears (9.2 mm) and supraspinatus tear (9.3 mm) shoulders compared to normals (3.5mm) and tendinopathy (4.8mm) shoulders (p = 0.05). Conclusion The Dynamic MRI enabled a novel measure; ‘Looseness’, i.e. the translation of the humeral head on the glenoid during an abduction cycle. Looseness was better able at differentiating different forms of rotator cuff disease than a simple static measure of relative glenohumeral position.

Acute felon and paronychia: Antibiotics not necessary after surgical treatment. Prospective study of 46 patients

Paronychia and felon are the most common infections of the hand. Surgical treatment is required once an abscess develops, but systematic use of postoperative antibiotic therapy remains open for discussion. Antibiotics both favor the selection of resistant bacteria and increase the cost of treatment. To our knowledge, no study has demonstrated their benefit following excision, yet many practitioners prescribe them systematically and empirically. In our current practices, we do not use antibiotic coverage following excision of uncomplicated paronychia or felon (no signs of arthritis, osteitis, flexor tenosynovitis, lymphangitis), except in potentially at-risk patients (immunosuppressed, diabetic, cardiac valve prosthesis recipient). Since this approach seems to lead to good outcomes, our objective was to evaluate them clinically in this study. Our prospective study included 46 patients who were not considered at risk. There were 26 cases of paronychia, 3 cases of felon and 17 patients presenting both paronychia and felon. All cases were abscessed and uncomplicated. All patients underwent surgical excision, and none received postoperative antibiotics. Follow-up took place on the day after surgery, at days 7, 14, 21 and 45. The main criterion for evaluation was healing of the infection and the wound. We recorded 45 cases of healing with no complications and a single case of recurrence. Surgical excision of paronychia or felon without antibiotic coverage gives excellent results with only rare recurrence. The single failure can be attributed to inadequate excision. Antibiotic therapy has no role in managing uncomplicated felon or paronychia in patients who are otherwise not at risk. Successful treatment depends above all on the completeness of the surgical excision.

New dynamic three-dimensional MRI technique for shoulder kinematic analysis.

To establish a new imaging technique using dynamic MRI three‐dimensional (3D) volumetric acquisition in real‐time, on six normal shoulders for the analysis of the 3D shoulder kinematics during continuous motion.

Endoluminal minimally invasive surgery for chronic exertional compartment syndrome: A new technique

INTRODUCTION Fasciotomy is the usual treatment for chronic exertional compartment syndrome of the lower limb. For esthetic reasons, minimally invasive techniques have been developed but can generate complications. Herein, we report the use of the KnifeLight during minimally invasive anterior and lateral compartment release in view of reducing these complications, within a feasibility study. MATERIAL AND METHODS This study was conducted on four cadavers (eight legs) and then an athletic patient (two legs). RESULTS The technique was carried out on all cases with no complications. The patients result was excellent. DISCUSSION The KnifeLight can be used to perform a fasciotomy of the legs anterior and lateral compartments. It seems to provide the operator with additional safety compared to other minimally invasive techniques. CONCLUSION This is a simple, reliable, and reproducible technique that deserves to be better known.

Shoulder Arthroplasty Imaging: What’s New

Background: Shoulder arthroplasty, in its different forms (hemiarthroplasty, total shoulder arthroplasty and reverse total shoulder arthroplasty) has transformed the clinical outcomes of shoulder disorders. Improvement of general clinical outcome is the result of stronger adequacy of the treatment to the diagnosis, enhanced surgical techniques, specific implanted materials, and more accurate follow up. Imaging is an important tool in each step of these processes. Method: This article is a review article declining recent imaging processes for shoulder arthroplasty. Results: Shoulder imaging is important for shoulder arthroplasty pre-operative planning but also for post-operative monitoring of the prosthesis and this article has a focus on the validity of plain radiographs for detecting radiolucent line and on new Computed Tomography scan method established to eliminate the prosthesis metallic artefacts that obscure the component fixation visualisation. Conclusion: Number of shoulder arthroplasties implanted have grown up rapidly for the past decade, leading to an increase in the number of complications. In parallel, new imaging system have been established to monitor these complications, especially component loosening

Patologías del codo y rehabilitación

El codo, una articulacion bisagra del miembro superior, esta particularmente expuesto a las patologias traumaticas, degenerativas e inflamatorias, pero tambien a las patologias nerviosas. El denominador comun de todas estas etiologias es el riesgo de aparicion de rigidez, que debe ser la preocupacion principal del terapeuta. El principal objetivo de la rehabilitacion del codo es, por tanto, la «prevencion de la rigidez». En la rehabilitacion se debe prohibir la practica de movilizaciones intempestivas y agresivas, pues estas son un motivo de fracaso terapeutico. Por el contrario, la rehabilitacion debe ser global y, sobre todo, integrar en sus esquemas motores los componentes de flexion-extension y de pronacion-supinacion. Una vez que se controlan la movilidad, la estabilidad y el dolor, es posible focalizar la rehabilitacion en la recuperacion de la velocidad de ejecucion y de la fuerza. En el contexto traumatico mas frecuente, el cirujano debe efectuar montajes estables que permitan una rehabilitacion precoz. La rigidez del codo es en si misma un fracaso del tratamiento. El tratamiento apropiado suele ser quirurgico y en todos los casos debe seguir una rehabilitacion no agresiva, persistente, que es la unica garantia de aumento de las amplitudes y de la recuperacion funcional.

Lésions nerveuses associées aux fractures de l’extrémité distale du radius

Nerve damage is a common complication of distal radius fractures. It may be a result of the injury event or be iatrogenic. It is the source of disability and potential handicap. There is little published data on this topic and no study has validated the strategies needed to prevent or manage these nerve-related complications. There is no consensus on treatment. Prevention requires a good knowledge of the various surgical approaches and rigorous fracture fixation technique. The objective of this article is to take stock of recent data from the scientific literature.

Distal sensory disorders in Dupuytren's disease

PURPOSE Dupuytrens disease is a common and disabling condition. Its pathophysiology is not well understood. Some patients complain of postoperative loss of fingertip sensitivity that could be due either to the surgery or to the disease itself. Our hypothesis is that distal sensory disorders are a component of Dupuytrens disease. METHODS We performed a prospective, single-center study to compare two populations: controls and patients with Dupuytrens disease. Subjects were excluded if they were under 18 years of age or had any disease or treatment that could alter finger sensitivity or test comprehension. Sensitivity was determined using Webers static two-point discrimination test. Each ray of the tested hand in the Dupuytrens patients was classified as healthy or diseased; the diseased rays were graded using the Tubiana stages and the type of involvement (pure digital, pure palmar, palmar-digital). RESULTS The study enrolled 56 patients in two comparable groups of 28 patients and 28 controls. A statistically significant difference was found between the affected hands of Dupuytrens patients and the hands of the controls. There was also a significant difference in the mean sensitivity of affected and normal rays in the Dupuytrens patients. CONCLUSION Preoperative distal sensory disorders are a component of Dupuytrens disease that could be related to neuropathy and/or mechanical nerve compression. LEVEL OF EVIDENCE IV, case-control study, diagnostic study.