Thierry Bégué

The concept of induced membrane for reconstruction of long bone defects.

Clinical, experimental, and fundamental studies have shown the interest of a foreign body-induced membrane to promote the consolidation of a conventional cancellous bone autograft for reconstruction of long bone defects. The main properties of the membrane are to prevent the resorption of the graft and to secrete growth factors. The induced membrane appears as a biological chamber, which allows the conception of numerous experimental models of bone reconstruction. This concept could probably be extended to other tissue repair.

Induced membrane for treatment of critical sized bone defect: a review of experimental and clinical experiences

PurposeThe purpose of this study was to review experimental and clinical experiences about the use of an induced membrane to address critical bone size defect of the limbs.MethodsFrom a review of published experimental and clinical data and from our clinical experience, we present the key data about the use of an induced membrane to address critical bone size defect of the limbs.ResultsAfter reviewing the concept of critical sized bone defect, we present the different indications of an induced membrane, the key points of the surgical technique and the strategy of bone grafting given the indication, localization and importance of the critical sized bone defect. Finally, we discuss the perspective of the use of an induced membrane with various bone substitutes.ConclusionsThe use of an induced membrane to treat critical sized bone defects of the limbs is a simple, reliable and reproducible technique. Certain technical steps should be pointed out and observed with great caution in order to avoid any pitfalls. This technique will probably be a key step for facilitating bone inclusion of new bone substitutes proposed by recent bioengineering.

Management of upper cervical spine fractures in elderly patients: current trends and outcomes

Upper cervical spine fractures in the elderly represent serious injuries. Their frequency is on the rise. Their early accurate diagnosis might be compromised by the existence of extensive degenerative changes and deformities. Adequate stabilisation allowing fracture healing is of paramount importance. However, the debate is ongoing as to the best protocol that can be applied taking into consideration the presence of comorbidities and the increase risk of mortality in this frail patient population. A literature review, based on PubMed, related to protocols reporting on fracture fixation of the upper cervical spine, fractures (C1-C2) was carried out. Papers including information about type of fracture, treatment carried out, complication rates, mortality and morbidities were eligible to be included in this study. Fourteen papers met the inclusion criteria. Six reported on all types of injuries of the upper cervical spine, and eight only odontoid fractures (C2). Overall mortality rate ranged between 0 to 31.4%. Overall morbidity rate was from 10.3 to 90.9%. No significant difference was identified between three types of treatment (rigid collar cuff without fracture reduction, halo cast with reduction of fracture displacement, and surgical treatment). Halo-cast got the highest rate of complications. Surgical treatment got a mortality rate from 0 to 40.0%, and a morbidity rate from 10.3 to 62.5%. Non-union rate ranged between 8.9 to 62.5%. Elderly patients with upper cervical spine fractures must be notified that these injuries are associated with high incidence of non-union, morbidity and mortality.

Anatomic study of the distally based vastus lateralis muscle flap.

The anatomy of the vascular perforation to the distal portions of the vastus lateralis muscle has been studied in 20 cadaver extremities to outline the vascular basis for distally based vastus lateralis muscle flap. From the 15.4 +/- 2.4, 11.8 +/- 1.7, and 7.9 +/- 2.0 cm distally to the patella, three quite large branches that issue from the deep femoral artery with the mean diameter of 2.8 +/- 0.2, 2.6 +/- 0.2, and 2.2 +/- 0.3 mm, respectively, distribute the distal parts of vastus lateralis muscle. These branches are thought to be an anatomic basis for the distally based vastus lateralis muscle flap. This allows the distally based vastus lateralis muscle flap to be raised for coverage of defects (1) in the popliteal fossa posterior and inferior portions of the knee anteriorly, (2) in the proximal one-third of the leg, and (3) for a below-knee amputation and the rotation of muscle tissue, such as when the gastrocnemius and soleus muscle are unavailable.

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.

Bioactive glass for long bone infection: a systematic review

BACKGROUND Long bone infection remains a challenging situation for the orthopaedic surgeon. For most, treatment comprises a thorough debridement of all the infected bone, the filling of the resultant cavity with a bone substitute, and general antibiotics for a certain time. However, the type of bone substitute to insert in the cavity is still debated. PURPOSE In this study, we aimed to systematically review the results of studies using bioactive glass for long bone infection in the clinical setting. MATERIAL AND METHOD We searched systematically Medline via Pubmed for studies published until August 2015 that report the results of bioactive glass for long bone infection in humans. RESULTS Three studies, including a total of 41 patients, met the inclusion criteria. Mean age was 46.5 (16-84). Twenty-nine were male and twelve were female. Period of inclusion went from 2007 to 2013. All the patients had a clinically and radiologically diagnosed osteomyelitis. They all underwent a state of the art surgical procedure to address osteomyelitis. All the patients were implanted with BAG-S53P4 granules (BonAlive Biomaterials Ltd, Turku, Finland) to fill in the resultant cavity. Mean volume inserted was 16.8 milliliters (2-60). After a mean follow-up of 21 months (10-38), three cases of osteomyelitis recurred. In two cases, a new procedure was performed. No complication directly related to the bioactive glass was reported. DISCUSSION Despite a limited use for long bone infection in humans, bioactive glass seems to be an interesting option as bone substitute after thorough bone debridement and skin coverage. It associates antibacterial activities, osteoconductive properties and vascular stimulation. CONCLUSION From this review, bioactive glass seems to be a useful bone substitute for long bone infection in humans. Few recurrences occurred after its use. In these cases, the volume of bone glass to insert was frequently underestimated and/or the skin coverage not adequate.

Le lambeau sural à pédicule distal à la cheville et au pied : analyse des complications à propos d’une série de 27 lambeaux

The distally based sural flap is widely used in foot and ankle skin and soft tissue repairs. It is described as an easy and reliable procedure. But in our experience, the flap necrosis was observed rather frequently. The analysis of this complication was the main goal of this retrospective study. The distally based sural flap has been used 27 times for skin repair at the foot and ankle. Twenty-six cases were post-traumatic. The success rate was 70%. Eight (mostly partial) necrosis occurred, one total necrosis lead to mid-leg amputation. In post-trauma reconstructions, this flap was not found so reliable. The rate of flap necrosis increases with age and comorbidities. No relationship could be established between the necrosis of the flap and its width. Heel and lateral localizations were found more risky. Technical modifications are discussed with a special focus on the two staged procedure.

Success rate and risk factors of failure of the induced membrane technique in children: a systematic review

The induced membrane technique was designed by Masquelet et al. to address segmental bone defects of critical size in adults. It has been used after bone defects of traumatic, infectious and tumoral origin with satisfactory results. Recently, it has been used in children but, after an initial enthusiasm, several cases of failure have been reported. The purpose of this study was to assess the success rate and the risk factors of failure of the induced membrane for children. We conducted a systematic review of all the studies reporting the results of the induced membrane technique to address bone defects of critical size in children. Our primary outcome was the success rate of the technique defined as a bone union before any iterative surgery. Our secondary outcomes were the complications and the risk factors of failure. We searched Medline via Pubmed, EMBASE and the Cochrane Library. Twelve studies, including 69 patients, met the inclusion criteria. There were 41 boys and 28 girls. Mean age at surgery was 10 years. Mean size of resection was 12.38 cm and the mean time between the two stages was 5.86 months. Mean rate of bone union after the two stages of the induced membrane technique was 58% (40/69) but this rate increased to 87% after revision surgeries (60/69). Main complications were non-unions (19/69), lysis of the graft (6/69) and fractures of the bone graft (6/69). Only 1/69 deep infection was reported. Other non specific complications were regularly reported such limb length discrepancies, joint stiffness and protruding wires. Risk factor of failure that could be suspected comprised the resection of a malignant tumour, a bone defect located at the femur, a wide resection, a long time between the two stages, an unstable osteosynthesis and a bone graft associating autograft to other graft materials. The induced membrane technique is suitable for bone defects of critical size in children. It is a reliable technique with no need of micro vascular surgery. However, we found several risk factors of failure for the use of the induced membrane technique to address segmental bone defect of critical size in children.

Diagnostic préopératoire des anses de seau méniscales : valeur des critères cliniques, arthro-TDM et IRM: À propos d’une série de 33 cas confirmés par arthroscopie

Resume L’objectif de cette etude etait d’analyser la pertinence des signes cliniques et l’apport des nouvelles modalites d’imagerie en coupe (arthro-TDM et IRM) pour le diagnostic preoperatoire d’un type de lesions meniscales longitudinales dites en anse de seau. Il s’agit d’une serie retrospective de 33 lesions meniscales en anse de seau confirmees arthroscopiquement, ayant beneficie d’un bilan preoperatoire comportant une arthrographie et/ou un arthro-TDM et/ou une IRM. Les examens ont ete relus par 2 radiologues seniors en consensus. Les principaux signes cliniques recherches etaient des antecedents de blocage typique et l’existence d’un flessum preoperatoire. Les signes radiologiques etudies correspondaient a la visualisation du fragment deplace, en coupe coronale (fragment dans l’echancrure) ou sagittale (megacorne anterieure, double LCP, signe du serpent). Les antecedents de blocage typique etaient retrouves 14 fois et un flessum 15 fois. Seuls 10 patients presentaient l’association evocatrice « blocage + flessum ». Le diagnostic positif de lesion meniscale en anse de seau etait porte en IRM (13/15), en arthro-TDM (6/7) et en arthrographie (10/24), soit une sensibilite equivalente pour les 2 techniques d’imagerie en coupe. Le signe du fragment dans l’echancrure en coupe coronale est un signe constant. Le signe du double LCP est un signe sensible pour les lesions du menisque medial et pour les lesions du menisque lateral en cas de rupture associee du LCA. 9 patients avaient eu plusieurs examens (n = 2 ou 3) et aucun faux negatif n’etait retrouve dans ce groupe. Dans 9 cas, le diagnostic d’anse de seau n’avait pas ete porte (Arthrographie : n = 7 ; IRM : n = 2). Dans ces cas, on peut incriminer l’etroitesse du fragment meniscal et parfois le delai entre le bilan et l’arthroscopie.PURPOSE OF THE STUDY It is important for both the patient and the surgeon to determine whether a meniscal lesion can be repaired before undertaking surgery. The purpose of this study was to examine the pertinence of clinical signs and determine the value of imaging findings for the preoperative diagnosis of bucket-handle meniscal tears. This preliminary study was conducted before undertaking an analysis of preoperative criteria of reparability in a homogeneous group of meniscal lesions. MATERIAL AND METHODS This retrospective series included 33 arthroscopically-proven bucket-handle meniscal tears in patients who underwent arthrography and/or arthroscan and/or MRI preoperatively. The images were reviewed by two senior radiologists who established a consensus diagnosis. Clinically, the type of blockage and the presence of permanent flexion before surgery were noted. The following items were noted on the imaging results: fragment displacement (fragment in the notch on the coronal slice) anterior megahorn, double PCL, and serpent sign on the sagittal slice. Longitudinal, transversal extension and position of the bucket-handle were noted. We searched for correlations with the intraoperative findings. RESULTS Fourteen patients had a history of knee blocking and 15 had permanent flexion before surgery. Only 10 patients had the typical association of blocking and flexion. Certain diagnosis of bucket-handle meniscal tear was provided by MRI (13/15), arthroscan (6/7), and arthrography (10/24) giving an equivalent sensitivity for the two slice imaging techniques. The sign of a fragment in the notch on the coronal slice was a constant finding. The double PCL sign was sensitive for medial meniscal tears and for lateral meniscal tears with associated ACL tears. The diagnosis was successfully established in all 9 patients who underwent several explorations (2 or 3). Buckle-handle meniscal tear was not identified in 9 patients (arthrography 7, MRI 2). DISCUSSION Our findings demonstrate that the preoperative diagnosis of bucket-handle meniscal tears cannot be properly established on clinical criteria of typical blocking and/or permanent flexion. They confirm that arthrography is not contributive to diagnosis and that the absence of a slice image is detrimental to diagnosis. The sensitivity of the two slice imaging methods was similar. The key sign was the presence of a fragment in the notch on the coronal slice; in the three cases where this sign was absent, the reason was found to be the small size of the displaced fragment (resolution limit) and time between imaging and arthroscopy. The characteristic features of the bucket-handle lesions observed in this series are exactly the same as reported in earlier reports but to our knowledge provide the first data on comparative performance of arthroscan and MRI. CONCLUSION The noninvasive nature of MRI and the possibility of assessing the meniscal wall and the quality of the meniscal tissue make MRI the exploration of choice for preoperative assessment of meniscal tears.

Early prosthetic joint infection due to Ureaplasma urealyticum: Benefit of 16S rRNA gene sequence analysis for diagnosis

Detection of the most frequently bacteria involved in prosthetic joint infection (PJI) is usually performed by conventional cultures. We report a case of early PJI due to Ureaplasma urealyticum, diagnosed by 16S rRNA gene sequence analysis, which highlights the interest of molecular methods if fastidious bacteria are involved in PJI.