Nicolas Bronsard

The T1 Pelvic Angle, a Novel Radiographic Measure of Global Sagittal Deformity, Accounts for Both Spinal Inclination and Pelvic Tilt and Correlates with Health-Related Quality of Life

BACKGROUND Adult spinal deformity is a prevalent cause of pain and disability. Established measures of sagittal spinopelvic alignment such as sagittal vertical axis and pelvic tilt can be modified by postural compensation, including pelvic retroversion, knee flexion, and the use of assistive devices for standing. We introduce the T1 pelvic angle, a novel measure of sagittal alignment that simultaneously accounts for both spinal inclination and pelvic retroversion. The purpose of this study was to investigate the relationship of the T1 pelvic angle and other established sagittal alignment measures and to correlate these parameters with health-related quality-of-life measures. METHODS This is a multicenter, prospective, cross-sectional analysis of consecutive patients with adult spinal deformity. Inclusion criteria were adult spinal deformity, an age of greater than eighteen years, and any of the following: scoliosis, a Cobb angle of ≥ 20°, sagittal vertical axis of ≥ 5 cm, thoracic kyphosis of ≥ 60°, and pelvic tilt of ≥ 25°. Clinical measures of disability included the Oswestry Disability Index (ODI), Scoliosis Research Society (SRS)-22, and Short Form-36 (SF-36) questionnaires. RESULTS Five hundred and fifty-nine consecutive patients with adult spinal deformity (mean age, 52.5 years) were enrolled. The T1 pelvic angle correlated with the sagittal vertical axis (r = 0.837), pelvic incidence minus lumbar lordosis (r = 0.889), and pelvic tilt (0.933). Categorizing the patients by increasing T1 pelvic angle (<10°, 10° to 20°, 21° to 30°, and > 30°) revealed a significant and progressive worsening in health-related quality of life (p < 0.001 for all). The T1 pelvic angle and sagittal vertical axis correlated with the ODI (0.435 and 0.455), SF-36 Physical Component Summary (-0.445 and -0.458), and SRS (-0.358 and -0.383) (p < 0.001 for all). Utilizing a linear regression analysis, a T1 pelvic angle of 20° corresponded to a severe disability (an ODI of >40), and the meaningful change in T1 pelvic angle corresponding to one minimal clinically important difference was 4.1° on the ODI. CONCLUSIONS The T1 pelvic angle correlates with health-related quality of life in patients with adult spinal deformity. The T1 pelvic angle is related to both pelvic tilt and sagittal vertical axis; however, unlike sagittal vertical axis, it does not vary on the basis of the extent of pelvic retroversion or patient support in standing. Since the T1 pelvic angle is an angular and not a linear measure, it does not require calibration of the radiograph. Thus, the T1 pelvic angle measures sagittal deformity independent of many postural compensatory mechanisms, and it can be useful as a preoperative planning tool, with a target T1 pelvic angle of < 14°. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Clinical and radiologic outcomes of pyrocarbon radial head prosthesis: midterm results

BACKGROUND The modular pyrocarbon (MoPyC) radial head prosthesis (Tornier, Saint-Ismier, France) is a monoblock modular radial head prosthesis. This study assessed midterm outcomes after implantation of the prosthesis. MATERIALS A retrospective study was conducted of a consecutive cohort of 65 patients who underwent radial head replacement with the MoPyC prosthesis from January 2006 to April 2013. Indications were fractures, early or late failures from orthopedic or fixation treatments, and revisions after another implant. Patients were observed for >2 years for range of motion, pain, and stability; function by the Mayo Elbow Performance Score (total score, 100) and grip strength were assessed. Quality of stem implantation, bone resorption around the neck, and periprosthetic lucency were noted and quantified on radiographs. Capitellum shape and density as well as humeroulnar aspect (river delta sign) were evaluated. Complications and revision procedures were noted. RESULTS We evaluated 52 of 65 patients (mean follow-up, 46 ± 20 months; range, 24-108). The Mayo Elbow Performance Score was 96 ± 7; pain score, 42 ± 7/45; and motion score, 18 ± 2/20. Function and stability were excellent. Radiology revealed 92% of patients with cortical resorption around the neck without mechanical failure. Bone resorption was mostly anterior and lateral; it resolved within the first year and thereafter was stable. Eight patients underwent revision surgery for stiffness. No implant failures were noted. CONCLUSION Results of the MoPyC radial head prosthesis appear to be satisfactory. Bone resorption around the neck (stress shielding) is frequent and stable after 1 year and does not impair stem fixation. The MoPyC prosthesis appears to be a reliable solution for replacing the radial head.

Can fluoroscopy radiation exposure be measured in minimally invasive trauma surgery

Repeated use of X-rays in orthopedic surgery poses the problem of irradiation of patient and caregivers. Seven common minimally invasive bone trauma surgical procedures requiring image intensifier use were investigated: percutaneous K-wire fixation of the wrist, minimally invasive fixation plating of the wrist, percutaneous intramedullary nailing of the tibia and of the femur, short and long trochanteric nail fixation of trochanteric and sub-trochanteric fracture, and percutaneous fixation of thoracolumbar fracture. The study analyzed three parameters: dose area product (DAP), radiation duration, and skin entrance dose (SED). Data were collected from 15 successive implementations of each procedure. The aim of the study was to establish a database for this kind of bone trauma surgery and a hierarchy of the X-ray doses delivered. Percutaneous spinal osteosynthesis involved the highest dose, followed in decreasing order by long trochanteric nailing, femoral nailing, short trochanteric nailing, tibial nailing, wrist K-wire fixation and frontal wrist plate osteosynthesis. One short trochanteric nail procedure delivered the same DAP as 13 wrist K-wire fixation procedures, and one spinal osteosynthesis was equivalent to 13 short trochanteric nail or 174 wrist K-wire procedures. The anatomic area X-rayed appeared to be the main radiation dose factor. A database was established, but actual patient and staff radiation levels remained unknown.

Centering of cervical disc replacements: usefulness of intraoperative anteroposterior fluoroscopic guidance to center cervical disc replacements: study on 20 discocerv (scient'x prosthesis).

Study Design. This is a prospective randomized computed tomographic scan study on the centering of cervical disc prosthesis (Discocerv; Scient’X) with and without anteroposterior (AP) fluoroscopic guidance. Objective. Analyze interest of AP fluoroscopic guidance for coronal positioning in cervical disc replacements. Summary of Background Data. This series consisted of 20 patients. One group of 10 patients was operated using only lateral fluoroscopic guidance (L guidance) and the other group of 10 patients was operated using both lateral and AP fluoroscopic guidance (AP + L guidance). Total disc replacements positioning is analyzed in the 2 groups. Methods. All patients had a computed tomographic scan 24 hours after surgery. Specific reconstructions were obtained from the native slices. Three planes P1, P2, and P3 are defined to quantify centering of the prosthesis in axial sagittal and coronal planes. Results. In the coronal plane P1, there is no difference in lateralization between the L guidance (absolute value of average M = 0.93 mm; SD = 0.59 mm) and AP + L guidance groups (M = 1.28 mm; SD = 0.75 mm). In the axial plane, there is no difference in lateralization between the L guidance and AP + L guidance groups. In the L guidance group, average was 1.96° (SD = 1.43°) and 3.18° (SD = 2.94°) in AP + L guidance. There is no significative difference between 2 groups in coronal (P = 0.26) and axial plane (P = 0.19). Conclusion. Unci are reliable landmarks for coronal centering of total disc replacements. AP fluoroscopic guidance does not improve this positioning.

Inferior Cubital Artery Perforator Flap for Soft-tissue Coverage of the Elbow: Anatomical Study and Clinical Application

BACKGROUND Soft-tissue defects surrounding the elbow can be a challenging problem for the orthopaedic surgeon. Reliable reconstruction with use of muscular flaps or even perforator flaps derived from the surrounding vessels has been described. The inferior cubital artery (ICA) is an indirect septocutaneous perforator branch that most frequently arises from the lateral side of the radial artery. The purposes of the present study were to characterize the capillary cutaneous perforators of the ICA and to evaluate the potential of a local perforator flap procedure for soft-tissue coverage of the elbow. METHODS Twenty fresh cadaveric forearms were dissected in order to describe the ICA anatomy, and in ten additional forearms the ICA was selectively injected with a red ink solution to detail the ICA vascular territory. For each artery, we recorded the site of origin, the diameter of the artery at its source, the course of the artery, and the number, type, and diameter of capillary cutaneous perforators. RESULTS A total of seventy-eight ICA capillary perforators were analyzed from the twenty dissected forearms: forty-six were in-transit capillary perforators, nineteen were terminal capillary perforators, and thirteen were musculocutaneous capillary perforators. Of these seventy-eight perforators, sixteen (21%) had a caliber of <0.5 mm and sixty-two capillary perforators (79%) had a caliber of ≥0.5 mm. Ten ICAs were selectively injected, and the mean size of all stained skin areas was 30.9 ± 11.9 cm(2). A perforator pedicled flap was readily feasible for all dissections. We also describe the case of a patient with a medial soft-tissue defect of the elbow that was covered with a pedicled perforator flap based on an ICA. The patient had satisfactory healing at two months. CONCLUSIONS The ICA flap is a reliable and useful flap for elbow soft-tissue reconstruction. CLINICAL RELEVANCE The perforator flap procedure is a major advancement in reconstructive surgery. One potential application of the perforator flaps is the use of tissue adjacent to a defect as a perforator-based island flap. The use of this tissue allows for thinner flaps to be tailored for more accurate reconstruction. A flap that depends on a perforator branch of the radial artery called the inferior cubital artery seems to be an excellent solution for soft-tissue coverage of the elbow.

One-stage percutaneous treatment in a patient with pelvic and vertebral compression fractures.

An active 38-year-old patient presenting a vertebral compression fracture associated with a pelvic fracture was treated in one stage with CT-guided fixation of the sacrum and kyphoplasty. This treatment decreased the pain, restored the vertebral height, and enabled the patient to be ambulatory. The main advantage of this double approach was to shorten the hospital stay and the nonworking period.

Is it possible to give a single definition of the rectosigmoid junction

AimThe rectosigmoid junction is the limit separating the sigmoid colon and rectum. This transition zone has different definitions. We want to highlight different landmarks of the rectosigmoid junction (RSJ), to help the clinicians to adopt a consensual definition.MethodWe reviewed anatomical, endoscopic, physiological and surgical points of view concerning the rectosigmoid junction (RSJ).ResultsThe rectosigmoid junction has a different definition depending on who is studying it. Nevertheless, it is a high pressure location, a place connecting different muscles organizations, neurological systems or vascular anastomosis. The clear pathophysiology of the RSJ is not yet determined with certainty, but its resection is essential for the therapeutic care of patients and also for the improvement of surgical skills. From a surgical point of view, anatomical landmarks has to be chosen: easily reproducible and identifiable. The disappearance of taenia coli (belonging to the colon) and the peritoneal reflection (recto-genital pouch), located below the upper rectum, seem the most reliable. The level of rectal section must, in any case, be below the promontory.ConclusionThere is not a single definition, but rather several definitions of the RSJ. Each one of them reflects one appearance of this region: embryological and anatomical evolution or clinical entity. From a surgical point of view, the criterion which seems to be the most reliable is the disappearance of taenia coli and the peritoneal reflection (recto-genital pouch).

T1 Slope Minus Cervical Lordosis (TS-CL), the Cervical Answer to PI-LL, Defines Cervical Sagittal Deformity in Patients Undergoing Thoracolumbar Osteotomy

ABSTRACT Background: Cervical kyphosis and C2-C7 plumb line (CPL) are established descriptors of cervical sagittal deformity (CSD). Reciprocal changes in these parameters have been demonstrated in thoracolumbar deformity correction. The purpose of this study was to investigate the development of CSD, using T1 slope minus cervical lordosis (TS-CL) to define CSD and to correlate TS-CL and a novel global sagittal parameter, cervical-thoracic pelvic angle (CTPA), with CPL. Methods: A multicenter, retrospective analysis of patients with thoracolumbar deformity undergoing three-column osteotomy was performed. Preoperative and postoperative cervical parameters were investigated. Linear regression for postoperative values resulted in a CPL of 4 cm corresponding to a TS-CL threshold of 17°. Patients were classified based on postoperative TS-CL into uncompensated (TS-CL > 17°) or compensated cohorts (TS-CL < 17°); the two were compared using an unpaired t test. Logistic regression modeling was used to determine predictors of postoperative CSD. Results: A total of 223 patients with thoracolumbar deformity (mean age, 57.56 years) were identified. CTPA correlated with CPL (preoperative r = .85, postoperative r = .69). TS-CL correlated with CTPA (preoperative r = .52, postoperative r = .37) and CPL (preoperative r = .52; postoperative r = .37). CSD had greater preoperative CPL (P < .001) and CTPA (P < .001). The compensated cohort had a decrease in TS-CL (from 10.2 to 8.0) with sagittal vertical axis (SVA) correction, whereas the uncompensated had an increase in TS-CL (from 22.3 to 26.8) with all P < .001. Reciprocal change was demonstrated in the compensated group given that CL decreased with SVA correction (r = .39), but there was no such correlation in the uncompensated. Positive predictors of postoperative CSD included baseline TS-CL > 17° (P = .007), longer fusion (P = .033), and baseline CTPA (P = .029). Conclusions: TS-CL and CTPA correlated significantly with established sagittal balance measures. Whereas reciprocal change in cervical and thoracolumbar alignment was demonstrated in the compensated cohort, the uncompensated population had progression of their cervical deformities after three-column osteotomy. Clinical Relevance: The balance between TS-CL mirrors the relationship between pelvic incidence minus lumbar lordosis in defining deformities of their respective spinal regions.

Early morbidity and mortality after single-stage bilateral TKR

INTRODUCTION Single-stage bilateral total knee replacement (TKR) has the advantages of requiring only one hospital stay and one anesthesia session, having a shorter rehabilitation period, and reducing the cost of patient care. However, this strategy is controversial because of the perioperative risk. We hypothesized that this strategy did not cause early perioperative mortality and that the early morbidity and readmission rates would be low when patients are selected based on their ASA score. METHODS This single-center retrospective study analyzed a cohort of ASA-1 and ASA-2 patients who underwent single-stage bilateral TKR over an 8-year period (2009 to 2016). The study cohort consisted of 116 patients, mainly women with mean age of 69 years at inclusion; 22.4% of patients were ASA-1 and 77.6% were ASA-2. Death and early complications during the first 90 days postoperative, the early readmission rate and the blood-sparing strategy were analyzed using the clinical and paraclinical data collected during the hospital stay, during the convalescent care center stay, and during the follow-up visits at 6 weeks and 3 months postoperative. The analysis was completed using the intrahospital software Clinicom, which allowed us to trace all the events and episodes for each patient. RESULTS The early mortality rate was 0%. There were five major complications (4.3%) and thirteen minor complications (11%). The early readmission rate was 5.2%. Homologous blood transfusion was performed in 36% of patients. Administration of tranexamic acid reduced this rate to 24.3% versus 44% in patients not taking it (p=0.06). CONCLUSION The perioperative mortality in this selected population is zero and the early morbidity is acceptable. The early readmission rate is also low. Thus proposing single-stage bilateral TKR to patients meeting the criteria defined in this study is a valid strategy. LEVEL OF EVIDENCE IV, retrospective cohort study.

Fracturas extracotiloideas del anillo pélvico en adultos

Las fracturas del anillo pelvico presentan un espectro de gravedad amplio, que va desde las lesiones estables y benignas hasta las lesiones inestables que comprometen la vida del paciente. Unos conocimientos adecuados de las relaciones anatomicas del anillo pelvico osteoligamentario permiten realizar la evaluacion completa de las lesiones asociadas para establecer las prioridades terapeuticas. El uso de clasificaciones obliga a realizar un analisis de las lesiones basado en la estabilidad y/o el mecanismo de produccion. La evaluacion y el tratamiento de los pacientes con inestabilidad hemodinamica que presentan una fractura pelvica se realizan simultaneamente: estabilizacion en primer lugar de la pelvis mediante un medio de contencion no invasivo, asociada a una reposicion vascular intensiva y a la busqueda de otra causa de hemorragia. La persistencia de la inestabilidad justifica la realizacion de una arteriografia con embolizacion, de un taponamiento extraperitoneal o de la combinacion de ambas medidas. En las fracturas pelvicas abiertas con lesion de la region perineal, debe realizarse una colostomia de derivacion precoz. El tratamiento multidisciplinario (reanimador, cirujano, radiologo intervencionista) es indispensable para la optimizacion terapeutica. Cuando se ha reanimado y estabilizado al paciente, el objetivo del tratamiento definitivo quirurgico es la restauracion anatomica del anillo pelvico para reducir las complicaciones y evitar las deformaciones residuales. La mejora del pronostico vial y funcional observada en los ultimos anos se relaciona con la aplicacion de distintas tecnicas de tratamiento precoces, asi como con el uso de metodos de fijacion definitivos menos invasivos, que se realizan secundariamente cuando el estado del paciente lo permite. Incluso con una reduccion anatomica pelvica, los resultados a largo plazo tras una fractura completa del anillo pelvico son modestos. Los problemas mas recurrentes con el dolor y las secuelas neurologicas y urogenitales.