Laurent Mathieu

Damage control orthopaedics in the context of battlefield injuries: the use of temporary external fixation on combat trauma soldiers.

INTRODUCTIONnThe purpose of this study was to analyze the use of temporary external fixation within the perspective of a damage control orthopedics attitude in the management of battlefield extremity injuries.nnnHYPOTHESISnDamage control orthopaedics (DCO) is a valuable treatment option for easy and rapid limb fracture stabilization in an unfavorable surgical environment.nnnMETHODSnSixteen French soldiers wounded on the battlefield between 2004 and 2009 and managed by damage control orthopedics were included in this retrospective series. All patients were males with a mean age of 30 years (20-53 years). Eighteen external fixators were applied on the theater of operations for multiple injuries (five cases), closed fractures of the pelvis or long bones (three cases) and open osteoarticular lesions (ten cases).nnnRESULTSnAfter medical evacuation from original theater, conversion to internal fixation was possible in five cases. External fixation was maintained in thirteen cases due to the severity of the lesions or infectious complications. Bone union was achieved in all cases. The mean time for bone union was 2.8 months (2 to 3 months) in case of conversion to internal fixation, and 6.3 months (1.5 to 17 months) when external fixation was extended. To achieve bone union, three devices were removed after a three or four month period and converted to rigid internal fixation associated with bone grafting. No case of septic complication was observed after early conversion. The only case of post-conversion infection occurred after three months of external fixation. After a mean follow-up of 19 months (6 to 49 months) all patients recovered functional autonomy and thirteen could return to duty.nnnCONCLUSIONnWhen possible, early conversion from external to internal fixation improves bone union and functional recovery after war limb injuries in properly selected patients.

Knee MR-arthrography in assessment of meniscal and chondral lesions

INTRODUCTIONnNo 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.nnnHYPOTHESISnMR-arthrography, represents in some pathologic situations, a more accurate source of information than conventional MRI.nnnMATERIALS AND METHODSnOver 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.nnnRESULTSnTo 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.nnnDISCUSSIONnIntra-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.

Temporary and definitive external fixation of war injuries: use of a French dedicated fixator

PurposeExternal fixation is the recommended stabilization method for both open and closed fractures of long bones in forward surgical hospitals. Specific combat surgical tactics are best performed using dedicated external fixators. The Percy Fx© (Biomet) fixator was developed for this reason by the French Army Medical Service, and has been used in various theatres of operations for more than ten years.MethodsThe tactics of Percy Fx© (Biomet) fixator use were analysed in two different situations: for the treatment of French soldiers wounded on several battlefields and then evacuated to France and for the management of local nationals in forward medical treatment facilities in Afghanistan and Chad.ResultsOverall 48 externals fixators were implanted on 37 French casualties; 28 frames were temporary and converted to definitive rigid frames or internal fixation after medical evacuation. The 77 Afghan patients totalled 85 external fixators, including 13 temporary frames applied in Forward Surgical Teams (FSTs) prior to their arrival at the Kabul combat support hospital. All of the 47 Chadian patients were treated in a FST with primary definitive frames because of delayed surgical management and absence of higher level of care in Chad.ConclusionTemporary frames were mostly used for French soldiers to facilitate strategic air medical evacuation following trauma damage control orthopaedic principles. Definitive rigid frames permitted achieving treatment of all types of war extremity injuries, even in poor conditions.

Teleconsultation in paediatric orthopaedics in Djibouti: evaluation of response performance.

BACKGROUNDnDjibouti has no paediatric orthopaedics department and three options are available for difficult cases: transfer of the patient to another country; overseas mission transfer to Djibouti by a specialised surgical team; and management by a local orthopaedic surgeon receiving guidance from an expert. The extreme poverty of part of the population of Djibouti often precludes the first two options. Telemedecine can allow the local orthopaedic surgeon to receive expert advice. HYPOTHESES AND STUDY DESIGN: We prospectively recorded all the paediatric orthopaedics teleconsultations that occurred between November 2009 and November 2011. Our objective was to assess the performance of the teleconsultations. We hypothetized that this option was influential in decision making.nnnMATERIALS AND METHODSnWe assessed the influence of the teleconsultation on patient management (i.e., change in the surgical indication and/or procedure). We then used the electronic patient records to compare the actual management to that recommended retrospectively by two independent orthopaedic surgeon consultants who had experience working overseas. Finally, we assessed the clinical outcomes in the patients.nnnRESULTSnOf 48 teleconsultations for 39 patients, 13 dealt with diagnostic problems and 35 with therapeutic problems. The teleconsultation resolved the diagnostic uncertainties in 90% of cases. Advice from the expert modified the management in 37 (77%) teleconsultations; the change was related to the surgical indication in 18 cases, the surgical technique in 13 cases, and both in six cases. Agreement between the advice from the independent consultants and the treatment delivered by the local surgeon was 2.2/3. Clinical outcomes were good or very good in 31 (81%) of the 38 treated patients.nnnCONCLUSIONSnThis study establishes the feasibility and usefulness of paediatric orthopaedics teleconsultations in Djibouti. The introduction of telemedicine has changed our approach to challenges raised by patients in remote locations or precarious situations. Input from experts considerably benefits patient management.nnnLEVEL OF EVIDENCEnIII, prospective comparative study.

Reconstruction of the Achilles Tendon with a Composite Anterolateral Thigh Free Flap with Vascularized Fascia Lata: A Case Report

Reconstruction of a segmental loss of the Achilles tendon combined with defects in soft-tissue coverage creates a challenge for the surgeon. We present the case of a patient who had combined loss of the Achilles tendon and overlying soft-tissue coverage. The patient was managed successfully with a single surgical procedure involving a composite anterolateral thigh free flap with vascularized fascia lata. The functional outcome of the reconstructed ankle and morbidity in the donor thigh were evaluated at one year with use of a kinetic dynamometer combined with magnetic resonance imaging.nnThe patient was informed that data concerning the case would be submitted for publication, and he consented.nnA forty-eight-year-old man sustained a complete rupture of the left Achilles tendon during military service. Primary suture repair of the tendon was performed. Four months after that operation, a new rupture occurred when the patient returned to work, and a second tendon repair was performed to reconstruct the defect with the central part of the proximal part of the Achilles tendon (the Bosworth procedure). A large hematoma formed postoperatively, followed by skin necrosis, resulting in a 12-cm segmental tendon loss with an overlying soft-tissue defect measuring 8 × 3 cm.nnThe wound site was debrided of all fibrous and necrotic tissue (Fig. 1). Because of the lack of suitable local tissue, a composite anterolateral thigh flap with attached vascularized fascia lata was harvested after a preoperative Doppler ultrasound examination. The main cutaneous perforator was located in the middle portion of a line between the anterior superior iliac spine and the lateral edge of the patella (Fig. 2). The skin paddle of the anterolateral thigh flap (17 × 8 cm) was designed to be slightly larger than the soft-tissue defect. It was harvested along with its vascular pedicle and a portion of the fascia …

Modern teaching of military surgery: why and how to prepare the orthopaedic surgeons before deployment? The French experience.

PurposeImproved survival of combat casualties in modern conflicts is especially due to early access to damage control resuscitation and surgery in forward surgical facilities. In the French Army, these small mobile units are staffed with one general surgeon and one orthopaedic surgeon who must be able to perform any kind of trauma or non trauma emergency surgery.MethodsThis concept of forward surgery requires a solid foundation in general surgery which is no longer provided by the current surgical programs due to an early specialization of the residents. Obviously a specific training is needed in war trauma due to the special pathology and practice, but also in humanitarian care which is often provided in military field facilities.ResultsTo meet that demand the French Military Health Service Academy created an Advanced Course for Deployment Surgery (ACDS), also called CACHIRMEX (Cours Avancé de CHIRurgie en Mission EXtérieure). Since 2007 this course is mandatory for young military surgeons before their first deployment. Orthopaedic trainees are particularly interested in learning war damage control orthopaedic tactics, general surgery life-saving procedures and humanitarian orthopaedic surgery principles in austere environments.ConclusionAdditional pre-deployment training was recently developed to improve the preparation of mobile surgical teams, as well as a continuing medical education for any active-duty or reserve surgeon to be deployed.

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.

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.

Soft tissue coverage of war extremity injuries: the use of pedicle flap transfers in a combat support hospital

PurposeDefinitive management of extremity injuries including soft tissue coverage is seldom achieved in battlefield medical treatment facilities due to limited resources and operational constraints. The purpose of this study was to analyse the French Army Medical Service experience performing such reconstructive surgery in a Combat Support Hospital (CSH) in Afghanistan.MethodsA clinical study was performed in the KaIA (Kabul International Airport) CSH from July 2012 to January 2013.ResultsDuring this period 23 Afghan patients treated for soft tissue coverage of combat-related extremity injuries were included. They totalled 28 extremity injuries including 18 blast trauma (BT) and ten non blast trauma (NBT). Overall, 35 extremity pedicled flaps were performed. There were 26 fasciocutaneous flaps, eight muscle flaps and one composite flap. Soft tissue coverage was achieved on all patients reviewed with a mean follow-up of 59xa0days. Five postoperative complications occurred including two deep infections, one partial flap necrosis and two flap failures, without difference according to injury mechanism.ConclusionReconstruction of traumatic soft tissue defect can be achieved in CSHs for local nationals. Pedicle flap transfers provide simple and safe coverage for war extremity injuries in this challenging environment whatever the injury mechanism.

Management of the complications of traditional bone setting for upper extremity fractures: the experiences of a French Forward Surgical Team in Chad.

The practice of traditional bone setting (TBS) in sub-Saharan Africa often leads to severe complications after upper extremity fracture. The purpose of this study was to evaluate the management of these complications by a French Forward Surgical Team deployed in Chad. An observational, prospective study was conducted over a six-month period between 2010 and 2011. During this period 28 patients were included. There were 20 males and 8 females with a mean age of 30.6 years (range 5-65 years). Thirteen patients (47%) had mal-union of their fracture, nine had non-union (32%), three children (10.5%) presented gangrene and three patients (10.5%) suffered from other complications. Fifteen (54%) patients did not undergo a corrective procedure either because it was not indicated or because they declined. Only 13 (46%) patients were operated on. Twelve of these patients were reviewed with a mean follow-up of 2.4 months. All of them were satisfied with conventional treatment. The infection seemed to be under control in every septic patient. Bone union could not be evaluated in most patients because of the short follow-up. Management of TBS complications is always challenging, even in a deployed Western medical treatment facility. Surgical expectations should be low because of the severity of the sequelae and the uncertainty of patient follow-up. Prevention remains the best treatment.