Marc Soubeyrand

Comparison of percutaneous dorsal versus volar fixation of scaphoid waist fractures using a computer model in cadavers.

PURPOSE Percutaneous screw fixation (PSF) is widely used to treat acute nondisplaced scaphoid waist fractures. PSF can be performed through a volar or dorsal approach. The aim of our study was to compare a dorsal versus volar surgical approach for PSF according to the sagittal orientation of the waist fracture (B1 or B2 in Herbert and Fishers classification scheme, in which B1 and B2 designate, respectively, oblique and transverse nondisplaced scaphoid waist fractures) on computer modeling of cadaver wrists. METHODS We used 12 upper limbs, and for each wrist we performed 3 computed tomography scans in maximal flexion, neutral position, and maximal extension. For each position, a parasagittal slice corresponding to the plane of ideal screw placement was obtained by numerical reconstruction. On each slice, we modeled B1- and B2-type fractures and the placement of the corresponding screws (S1 and S2) inserted through a volar or dorsal approach. Optimal screw orientation was perpendicular to the fracture. For each configuration, we measured the angle between the S1 screw and B1 fracture, which we designated V1 when modeling volar PSF and D1 when modeling dorsal PSF. Similarly, we measured angles V2 and D2. RESULTS For B2 fractures, virtual screw placement perpendicular to the fracture was achieved equally well with the 2 approaches. For B1 fractures, the virtual screw could not be placed perpendicular to the fracture with either approach, but the dorsal approach with maximal wrist flexion allowed the best screw placement. CONCLUSIONS For B2 fractures, the dorsal and volar approaches allow optimal virtual screw placement, and the choice of the approach depends on the surgeons preference. For B1 fractures, we recommend the dorsal approach.

Original portals for arthroscopic decompression of the suprascapular nerve: An anatomic study

Operative treatment of suprascapular nerve entrapment consists of decompression of the nerve, either at the suprascapular notch or the spinoglenoid notch. The aim of this study was to describe new arthroscopic portals to approach these 2 notches at the same time. Twenty shoulders in 10 fresh frozen cadavers were investigated. Four portals were used in line with the scapular spine (S1, S2, S3, S4). The suprascapular pedicle was visualized passing under the supraspinatus muscle. The technique was performed for each specimen. The efficacy and safety of the technique were assessed by open dissection. No injury to the nerve was identified after performing the technique. Decompression was complete in 18 of 20 cases at the suprascapular notch and in all cases at the spinoglenoid notch. With this technique, arthroscopic decompression of the nerve at the suprascapular and spinoglenoid notches is anatomically possible.

The middle radioulnar joint and triarticular forearm complex

The forearm is composed of the radial and ulnar shafts, which are linked by the interosseous membrane and intercalated between the elbow and wrist. The radius and ulna are connected by three joints, the proximal, middle, and distal radioulnar joints. The forearm ensures pronation/supination and longitudinal load transfer. The biomechanical and clinical relevance of the proximal and distal radioulnar joints is well established. In contrast, the middle radioulnar joint was considered relatively unimportant until studies published in the last decade showed that it fulfils crucial biomechanical functions and is of considerable clinical significance. We believe the conventional concept in which the forearm is viewed as part of either the elbow or the wrist is outdated and that a more relevant concept describes the forearm as a triarticular complex that functions as a full-fledged entity. In this concept, the three forearm radioulnar joints (proximal, middle, distal) work together to provide stability, mobility and load transfer. Here, we will argue for the relevance of the triarticular complex concept based on published data about forearm biomechanics and pathological conditions.

Penetrating Volar Injuries of the Hand: Diagnostic Accuracy of US in Depicting Soft-Tissue Lesions

PURPOSE To evaluate the effectiveness of ultrasonography (US) in depicting lesions of the tendons, arteries, and nerves caused by penetrating wounds of the volar aspect of the hand, with surgical exploration as the reference standard. MATERIALS AND METHODS Consecutive patients seen at one center over a 2-month period in 2006 were prospectively included. The institutional review board approved the study, and each patient gave written informed consent. There were 30 injuries in 26 patients (19 men and seven women; median age, 34 years). US examination was performed before surgery. Surgeons were not informed of the US findings. For tendons, arteries, and nerves, the sensitivity, specificity, positive predictive value, and negative predictive value of US were computed. RESULTS US depicted all tendon lesions, with no false-positive findings; two arterial lesions were missed, with no false-positive findings, and four nerve lesions were missed, with six false-positive findings. The negative predictive value was 100% (95% confidence interval: 95.5%, 100%) for tendons, 96.7% (95% confidence interval: 88.7%, 99.6%) for arteries, and 93.7% (95% confidence interval: 84.5%, 98.2%) for nerves. In three cases, US depicted foreign bodies missed at surgery. CONCLUSION US was highly effective in identifying patients with no tendon or arterial lesions. Performance was poorer for diagnosing nerve lesions. US followed by a repeat physical examination after 72 hours to look for missed nerve damage may deserve evaluation as an alternative to routine surgical exploration when US findings are normal.

Real-time and Spatial Quantification Using Contrast-enhanced Ultrasonography of Spinal Cord Perfusion During Experimental Spinal Cord Injury

Study Design. Experimental study in male Wistar rats. Objective. To quantify temporal and spatial changes simultaneously in spinal cord blood flow and hemorrhage during the first hour after spinal cord injury (SCI), using contrast-enhanced ultrasonography (CEU). Summary of Background Data. Post-traumatic ischemia and hemorrhage worsen the primary lesions induced by SCI. Previous studies did not simultaneously assess temporal and spatial changes in spinal cord blood flow. Methods. SCI was induced at Th10 in 12 animals, which were compared with 11 sham-operated controls. Spinal cord blood flow was measured in 7 adjacent regions of interest and in the sum of these 7 regions. Blood flow was quantified using CEU with intravenous microbubble injection. Spinal cord hemorrhage was measured on conventional B-mode sonogram slices. Results. CEU allowed us to measure the temporal and spatial changes in spinal cord blood flow in both groups. In the SCI group, spinal cord blood flow was significantly decreased in the global region of interest (P = 0.0016), at the impact site (epicenter), and in the 4 regions surrounding the epicenter, compared with the sham group. The blood flow decrease was maximum at the epicenter. No statistically significant differences between the sham groups were found for the most rostral and caudal regions of interest. Hemorrhage size increased significantly with time (P < 0.0001), from 30.3 mm2 (±2) after 5 minutes to 39.6 mm2 (±2.3) after 60 minutes. Conclusion. CEU seems reliable for quantifying temporal and spatial changes in spinal cord blood flow. After SCI, bleeding occurs in the spinal cord parenchyma and increases significantly throughout the first hour.

Intraoperative Ultrasonography During Percutaneous Achilles Tendon Repair

Background: The purpose of the study was to determine whether real-time intraoperative ultrasonography improved implant positioning and stump approximation in patients with acute Achilles tendon rupture managed percutaneously. Materials and Methods: The needles were introduced percutaneously without ultrasonography and their position was checked relative to cutaneous landmarks and by palpation. Then, intraoperative ultrasonography was performed to assess needle position at the proximal tendon segment, tendon tear, and distal tendon segment. Incorrectly placed needles were removed and reinserted under real-time ultrasonographic guidance. Tendon apposition was checked ultrasonographically. Results: We included 21 patients (19 males, two females) with unilateral acute Achilles tendon rupture, in whom 42 needles (one medial and one lateral) were inserted. Correct positioning was achieved without ultrasonographic guidance for 19 (45%) needles overall, 15 of 21 (71%) medial needles, and four of 21 (19%) lateral needles. The remaining 23 needles were correctly repositioned under ultrasonographic guidance. The correct positioning rates with and without ultrasonography differed significantly for all needles (p < 0.0001) and for lateral needles (p < 0.0001) but not for medial needles (p = 0.03). Intraoperative ultrasonography confirmed tendon stump approximation in all cases. Conclusion: Without imaging, 55% of needles were correctly positioned. Intraoperative ultrasonography allowed correct positioning of all needles and provided intraoperative confirmation of stump approximation. Level of Evidence: IV, Case Series

Acute bilateral posterior dislocation of the shoulder: one-stage reconstruction of both humeral heads with cancellous autograft and cartilage preservation.

We present a case of bilateral posterior shoulder dislocation after an epileptic seizure. The anterior humeral-head impression fracture was 60% of the articular surface on the right shoulder and 30% on the left shoulder. We performed an early one-stage reconstruction of both humeral heads. A cancellous autograft was used on the left side and an iliac cortico-cancellous autograft on the right side, with preservation of the patients cartilage. Three years later, the clinical and morphological results were excellent. The discussion focuses on surgical options that range from conservative treatment with excision of the damaged cartilage to immediate hemiarthroplasty. This case is original because of the preservation of the patients cartilage during reconstruction.

Preoperative imaging study of the spinal cord vascularization: Interest and limits in spine resection for primary tumors

The necessicity to localize the anterior spinal arteries before anterior approach of the spine stays controversial by orthopaedic surgeons. On the other hand the surgical treatment of thoracoabdominal aneurisms routinely sacrifices many segmental arteries pairs without spinal arteries localization. This, associated with spinal cord protection, results to few neurological complication. However, during vertebrectomies, the roots ligation completely interrupts the spinal cord blood supply at this level. In our experience the spinal arteries localization was systematically done before ninety-eight spine resections. In five cases an anterior radiculomedullary artery was ligated (four anterior radiculomedullary and one great anterior radiculomedullary arteries) without neurological complication, in two cases of extended resection (more than four levels) a neurological complication occurred. No spinal artery was identified at the resection level and the neurological complications were resolutive and did not seem related to definitive vascular problem. These accomplishments lead to discuss the importance of spinal arteries localization and preservation in this surgery. The discovery of an anterior radiculomedullary artery is not a contraindication to en-bloc vertebrectomy at this level, nevertheless in the case of great anterior radiculomedullary artery (Adamkiewicz) the surgical indication must be seriously debated. In fact, this case and those where multilevel resections (more than three levels) are indicated seem the most dangerous situations and the use of the different means of spinal cord protection could be indicated to decrease neurological risk. So before spine resection the spinal arteries localization could improve patient information and give more deciding factors for planning treatment.

Severe Open Ankle Sprain (SOAS): A Lesion Presenting as a Penetrating Soft Tissue Injury

The objective of this retrospective case study was to describe the incidence and clinical features of severe open ankle sprain (SOAS), defined as a tear of the lateral or medial collateral ligaments with an associated transverse tear of the skin over the corresponding malleolus. To this end, we reviewed the medical records of patients with SOAS managed between January 2005 and January 2009, using the databases of 3 different orthopedic trauma centers. Our review revealed 9 patients with SOAS, 7 (77.77%) of which involved the lateral ligaments and 2 (22.22%) of which involved the medial ligaments. The median age was 32 (range 21 to 45) years, and the injury occurred as a result of a motor vehicle accident in 6 (66.67%) patients, and as a result of a fall from a height in 3 (33.33%) patients. Two tendons were damaged in 2 (22.22%) patients, the deep fibular nerve (deep peroneal nerve) in 2 (22.22%) patients, and the anterior tibial artery in 1 (11.11%) patient. The only abnormality on plain radiographs was pneumarthrosis, which was present in 5 (55.56%) patients. The incidence of SOAS is rare, accounting for 0.002% (9/438,000) of all trauma cases and 0.22% (9/4142) of all cases of ankle trauma. The diagnosis was confirmed by intraoperative stress-maneuvers in all 9 patients. In conclusion, SOAS should be suspected in patients who present with a traumatic skin wound over the malleolus.

Feasibility assessment of shear wave elastography to lumbar back muscles: A radioanatomic study

Low back pain is often associated with tensional changes in the paraspinal muscles detected by palpatory procedures. Shear wave elastography (SWE), recently introduced, allows the stiffness of muscles to be assessed noninvasively. The aim of this work was to study the feasibility of using SWE on the three main lumbar back muscles (multifidus, longissimus, and iliocostalis) in vivo after analyzing their muscular architecture ex vivo. We determined the orientation of fibers in the multifidus, longissimus, and iliocotalis muscles in seven fresh cadavers using gross anatomy and B‐Mode ultrasound imaging. We then quantified the stiffness of these three muscles at the L3 level ex vivo and in 16 healthy young adults. Little pennation was observed in the longissimus and iliocostalis, in which the direction of fibers was almost parallel to the line of spinous processes. The multifidus appeared as a multiceps and multipennate muscle. Given the random layering of millimetric fascicles, tendons, and fatty spaces, the multifidus had multiple fiber orientations. Muscular fascicles and fibers were oriented from 9° to 22° to the line of spinous processes. The shear moduli related to stiffness were 6.9 ± 2.7 kPa for the longissimus, 4.9 ± 1.4 kPa for the iliocostalis, and 5.4 ± 1.6 kPa for the multifidus. SWE is a feasible method for quantifying the stiffness of the lumbar back muscles. Clin. Anat. 30:774–780, 2017.