Olivier Barbier

INJURY TO THE BRACHIAL PLEXUS BY A FRAGMENT OF BONE AFTER FRACTURE OF THE CLAVICLE

Clavicular fractures are occasionally responsible for lesions of the brachial plexus. The symptoms are usually delayed and due to compression by hypertrophic callus, nonunion or a subclavian pseudoaneurysm. We describe a patient in whom a displaced bone fragment was pressing on the retroclavicular part of the brachial plexus, leading to early symptoms of a lesion of the posterior cord. Internal fixation of the clavicle and external neurolysis of the brachial plexus gave an almost full recovery.

Vascularized osteochondral graft from the medial femoral trochlea: anatomical study and clinical perspectives

PurposeFew donor sites for vascularized reconstruction of convex joint surfaces have been described. We studied the feasibility of a convex vascularized osteochondral graft harvested from the medial femoral condyle and trochlea, on an anatomical and practical point of view.MethodsAn injection-corrosion technique was used on 16 fresh cadaver specimens, and completed by a modified Spalteholz clearing. The extra- and intraosseous vascularization of the medial femoral condyle was systematized and the luminal diameter of the arteries was microscopically measured. Radii of curvature of the medial trochlea and of the carpal bones were measured on arthro-CT-scanner reconstructed images.ResultsThe periosteal vessels of the medial condyle are responsible for the whole peripheral intraosseous vascularization, without any watershed region. They are fed by the articular branch of the descending genicular artery and/or the superomedial genicular artery. Several constant vascular axes can be found, and may serve as a pedicle for a vascularized osteochondral graft from the medial femoral trochlea. The radii of curvature of this graft do fit those of the proximal carpal row. A simple surgical approach is suggested.ConclusionsA vascularized graft harvested on the medial femoral trochlea is a technically feasible procedure that could represent a new reconstructive tool for convex joint surfaces. Osteonecrosis of the proximal pole of the scaphoid or Kienböck’s disease are among several situations where such a graft could be beneficial.

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.

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.

Reconstruction du coude par allogreffe massive ostéo-articulaire totale : échec précoce par instabilité

Total elbow allografts were implanted for the treatment of trauma-induced bone defects in three patients between 1986 and 1990. Six allografts were implanted and finally explanted. The longest follow-up for an implanted allograft was five years. Allografts had to be removed because of nonunion in one patient and gross instability in the others. A constrained elbow prosthesis was implanted in all three patients. This short series illustrates mid-term failure to be expected with total elbow allografts, mainly due to instability. Accordingly, we no longer recommend the use of total elbow allografts alone as a salvage procedure for bony defects. If an allograft is needed, it should be implanted with a prosthesis.Resume Trois patients ont eu une reconstruction du coude par allogreffe massive de coude entre 1986 et 1990. Il s’agissait de coudes ballants d’origine post-traumatique. Toutes les allogreffes ont ete retirees, soit pour pseudarthrose dans un cas, soit pour instabilite chez les autres. La plus longue duree d’implantation a ete de 5 ans. Toutes les reconstructions se sont terminees par une prothese de coude dont la mise en place n’a pas pose de probleme particulier. Cette experience est un echec et signifie pour nous que toute reconstruction d’articulation par une allogreffe osteo-articulaire complete doit etre abandonnee. Si une allogreffe doit etre implantee au niveau du coude, elle doit l’etre avec une prothese.

Biased visuospatial perception in complex regional pain syndrome

Complex regional pain syndrome (CRPS) is a chronic pain condition associating sensory, motor, trophic and autonomic symptoms in one limb. Cognitive difficulties have also been reported, affecting the patients’ ability to mentally represent, perceive and use their affected limb. However, the nature of these deficits is still a matter of debate. Recent studies suggest that cognitive deficits are limited to body-related information and body perception, while not extending to external space. Here we challenge that statement, by using temporal order judgment (TOJ) tasks with tactile (i.e. body) or visual (i.e. extra-body) stimuli in patients with upper-limb CRPS. TOJ tasks allow characterizing cognitive biases to the advantage of one of the two sides of space. While the tactile TOJ tasks did not show any significant results, significant cognitive biases were observed in the visual TOJ tasks, affecting mostly the perception of visual stimuli occurring in the immediate vicinity of the affected limb. Our results clearly demonstrate the presence of visuospatial deficits in CRPS, corroborating the cortical contribution to the CRPS pathophysiology, and supporting the utility of developing rehabilitation techniques modifying visuospatial abilities to treat chronic pain.

Initial Deployment of the 14th Parachutist Forward Surgical Team at the Beginning of the Operation Sangaris in Central African Republic

As part of the operation Sangaris begun in December 2013 in the Central African Republic, the 14th Parachutist Forward Surgical Team (FST) was deployed to support French troops. The FST (role 2 in the NATO classification) is a mobile surgical-medical treatment facility. The main goal of the FST is to assure the initial damage control surgery and resuscitation for combat casualties, allowing for the early evacuation to combat support hospitals (roles 3 or 4), where further treatments are completed. During the first trimester of the operation Sangaris, 42 patients were treated at FST, of whom 29 underwent surgery. Almost 50% of patients operated on were French servicemen. All admissions were emergency admissions. Orthopedic surgery represented two-thirds of surgical interventions executed as a result of the high proportion of limb injuries. Fifty percent of injuries were specifically linked to combat. Surgery in an FST is primarily dedicated to the treatment of combat casualties with hemorrhagic injuries, but additionally plays a part in supporting general medical care of French troops. Medical aid to the general civilian population is justifiable because of the presence of medical treatment facilities, even in the initial implementation of a military operation.

Pseudotumoral ganglion cyst of a finger with unexpected remote origin: multimodality imaging

The case of a ganglion cyst in the pulp of a fifth finger in an elderly woman initially mimicking a soft tissue tumor is described. Most typical sites of ganglion cysts are well documented at the wrist and in the vicinity of inter-phalangeal and metacarpo-phalangeal joints. In this case, ultrasonography (US) and magnetic resonance imaging (MRI) demonstrated a cystic lesion within the pulp of the fifth finger and indicated carpal osteoarthritis as the distant—and unexpected—origin of the lesion. The suggested diagnosis of ganglion cyst was confirmed by computed tomography arthrography (CT arthrography) of the wrist, which showed opacification of the cyst on delayed acquisitions after intra-articular injection into the mid-carpal joint, through the fifth flexor digitorum tendon sheath. The communications between the degenerative carpal joint, the radio-ulnar bursa, the fifth flexor digitorum tendon sheath and the pedicle of the cyst were well demonstrated.

Training for treating open fractures in the austere setting

Dear Editors, We read with interest the study by Bertol at al. reviewing the orthopaedic surgical activities performed during the Haiti earthquake of 2010 and in three ongoing projects: Médecins Sans Frontières, Operational Centre Brussels (MSF-OCB) and Democratic Republic of Congo and Afghanistan [1]. It provides a detailed description of treatments of open fractures in relation to surgical-staff skills and humanitarian contexts, with considerations for decision making about amputations or limb salvage in precarious situations. During the emergency response to the Haiti earthquake, the majority of interventions (81 %) performed on open-fracture cases were amputations, whereas in long-term projects, this rate decreased with mission duration (10–20%). The authors emphasised that training on the proper use of external fixators reduced the amputation rate in humanitarian contexts. The decision to proceed with limb salvage or amputation for patients with severely injured limbs was always a source of debate, especially in poor countries where it is difficult to access facilities for rehabilitation and prosthetic fitting [2]. This decision requires great surgical experience [3], and, as Dr. Bertol said, only few surgeons have this experience. In our experience, in a precarious environment, indications for amputation are not the same as those in daily practice and depend on several factors: the form warfare or disaster takes, the conditions for surgery, surgical-team skill, surgeon experience and mission duration [3]. Four indications of amputation could be distinguished:

Surgical support during the terrorist attacks in Paris, November 13, 2015: Experience at Bégin Military Teaching Hospital.

BACKGROUND Recent conflicts have allowed the French Army Health Service to improve management quality for wartime-injured people during military operations. On November 13, 2015, it was in Paris that France was directly attacked and Bégin Military Teaching Hospital, like several hospitals in Paris, had to face a large number of gunshot victims. Thanks to our operational experience, injured people hospitalized in military hospitals benefited from a management based on triage and damage control (DC) principles. METHODS Forty-five patients were taken care of in our hospital with an average age of 32 years. During triage, eight patients were categorized T1 (with four extreme emergencies) and 10 were classified T2 and 27 as T3. Twenty-two patients underwent emergency surgery, 15 for soft tissue lesions of limbs, 8 for ballistic fractures (one of which was a cervical wound), and 5 for abdominal wounds. Two patients classified T1 died early. RESULTS In total, more than 50 operations were performed including iterative debridements, bone fixation, three amputations, and two flaps. After 9 months, all of the patients had healed. One woman with limb stiffness required an arthrolysis. CONCLUSION This event showed that terrorist attacks and mass casualties with war wounds can occur in France. Acquired experience regarding war wounds by the French Army Health Service is precious. Everyone must understand the importance of triage and the principles of damage control. Every hospital must be ready to face this type of massive influx of injured people (white plan). LEVEL OF EVIDENCE Epidemiological study, level V.