[Targeting anticoagulated patients for medication reconciliation at discharge in orthopaedic surgery]. / Conciliation médicamenteuse de sortie ciblée en chirurgie orthopédique : focus sur les anticoagulants.

In orthopedic surgery, the well-known iatrogenic risk of oral anticoagulants is particularly increased due to surgical management (suspension and resumption of treatment). In order to prevent avoidable iatrogenic events linked to incomplete discharge documents, targeted medical reconciliation (MR) has been deployed. This is a single-center prospective study conducted in orthopaedic surgery for six months including any patient treated upon admission with an oral anticoagulant. The analysis of the compliance of discharge documents (hospitalization report and prescriptions) was carried out before and after pharmaceutical interventions. The criteria analysed included the mention of the oral treatment, its dosage as well as the supervision of the switch from heparin therapy to the usual oral treatment. The documents were compliant if the mention of oral anticoagulant treatment and the date of the shift were correctly documented. Thirty-seven patients were included. The compliance rate of discharge documents was significantly improved by MR, going from 13.5 % to 78.4 % (P <0.05). The non-compliances before the intervention concerned the absence of mention of: the usual treatment (64.9 %), its dosage (81.1 %) or the switch's securing (75.7 %). Discharge from surgery of the patient on anticoagulants is a stage presenting a real risk which can be managed by the intervention of pharmacists. Improving the compliance of discharge documents is a first step towards better securing drug management.

[Plastic surgery and fighting: Our experience during Nagorno-Karabakh war in 2020]. / Chirurgie plastique et conflit armé : notre expérience lors du conflit au Haut-Karabakh en 2020.

INTRODUCTION: This work relates the experience of three French surgical missions in the care of the war wounded during the armed conflict in Nagorno Karabakh which took place from September 27 to November 10, 2020. MATERIALS AND METHODS: Three surgical missions were carried out in Armenia between October 2020 and January 2021. Surgeons intervened in different hospitals, at different times of the conflict and on various war wounds. RESULTS: The presence of a plastic surgeon proved to be essential in the care of war wounded, especially in delayed emergency and secondary care. The ortho-plastic treatment offered during these missions has proven to be effective in the reconstruction of limbs. These missions made it possible to introduce the induced membrane technique of Masquelet AC in Armenia. During our visit to the Yerevan burn center, we mentioned the very probable use of white phosphorus as an etiology in several of the cases analyzed. CONCLUSION: We relate the particular experience of civilian surgeons in the context of a modern armed conflict. The presence of a plastic surgeon proved to be indispensable in the care of war wounded and especially in their secondary reconstructions.

[Design and assessment of a outpatient living with PICC-line support program: A pilot study]. / Étude pilote d'évaluation d'un programme d'accompagnement pour les patients quittant l'hôpital avec un PICC-line.

The peripheral insertion central catheter (PICC-Line) is indicated for long term intravenous medication administration. Some adverse events (AE) might occur, especially for patients after hospital discharge. Therefore, patient empowerment about the side effects and precaution for use is essential to prevent potential patient harm. A multidisciplinary working group met and designed support program for outpatient living with PICC-line. Pharmacy consultations (PC) were proposed to patient before and after PICC-line insertion. A strip cartoon and card game were created to facilitate patient education. The aim of the study was to assess the comprehension of patient then secondarily to follow up AE awareness. During 10 months, 30 patients of mean age 65.9±14 years were included. Thirty-sixPICC-Line were installed and followed on 1659days of catheterization. 4, 9 and 13patients received respectively no, at least one and two PCs before discharge from the hospital. Although the differences were not statistically significant, comprehension tends to improve when patients benefit from both PCs especially when it concerns complications. Twenty-fiveambulatory AEs were recorded including 9infections or suspicion of infection, 2 thrombosis and 2 displacements of PICC-line. Among the patients who had no PC, four experienced delayed care. In comparison, it occurred in only one patient in the group who received at least one PC after PICC-line insertion. Further studies are warranted to confirm this trend.

A global call to action to improve the care of people with fragility fractures.

The ageing of society is driving an enormous increase in fragility fracture incidence and imposing a massive burden on patients, their families, health systems and societies globally. Disrupting the status quo has therefore become an obligation and a necessity. Initiated by the Fragility Fracture Network (FFN) at a "Presidents' Roundtable" during the 5th FFN Global Congress in 2016 several leading organisations agreed that a global multidisciplinary and multiprofessional collaboration, resulting in a Global Call to Action (CtA), would be the right step forward to improve the care of people presenting with fragility fractures. So far global and regional organisations in geriatrics/internal medicine, orthopaedics, osteoporosis/metabolic bone disease, rehabilitation and rheumatology were contacted as well as national organisations in five highly populated countries (Brazil, China, India, Japan and the United States), resulting in 81societies endorsing the CtA. We call for implementation of a systematic approach to fragility fracture care with the goal of restoring function and preventing subsequent fractures without further delay. There is an urgent need to improve: To address this fragility fracture crisis, the undersigned organisations pledge to intensify their efforts to improve the current management of all fragility fractures, prevent subsequent fractures, and strive to restore functional abilities and quality of life.

Iatrogenic peritonitis following an incident during ablation of a pedicle screw.

Immediate complications can arise due to faulty implantation of material during fusion procedures, but none have been reported in connection with ablation of material in the spine. We report a case of intraperitoneal migration of a pedicle screw during attempted removal. It crossed the psoas muscle and perforated a small-intestine loop, triggering hemorrhagic shock and peritonitis by perforation. We analyze the causes and mechanisms underlying this exceptional case of migration, with a view to sharing preventive measures. Initial extra-pedicular screw positioning and the pressure exerted to remove it were responsible for this serious incident.

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.

External fixation of the thalamic portion of a fractured calcaneus: a new surgical technique.

The optimal treatment for intra-articular calcaneus fractures remains controversial, despite internal fixation techniques providing good results. The major point of contention is the need to reconstruct the overall morphology versus to restore the anatomy of the subtalar joint perfectly. We will describe a two-stage technique for treating intra-articular calcaneus fractures in which the primary fracture line goes through the thalamic fragment. The first procedure focuses on the overall morphology by restoring the height and length with osteotaxis being accomplished with a medial external fixator. The second procedure consists of internal fixation through a minimally invasive lateral approach to restore the anatomy of the articular facets. Any defects are filled with injectable bone substitute. This novel technique is compared to the complication rates and radiology and anatomy outcomes in published studies. This two-stage surgical technique reduces the length of hospital stays and the number of complications.

Articular fractures of the distal humerus.

Distal humeral fractures represent 2% of all adult elbow fractures. Injury mechanisms include high-energy trauma with skin involvement, and low energy trauma in osteoporotic bone. Treatment goals are anatomical restoration in young, high-demand patients and quick recovery of activities of daily living in the elderly. Complete fractures are relatively easy to diagnose, but partial intra-articular fractures are not. The clinical diagnosis must take into account potential complications such as open injuries and ulnar nerve trauma. Standard X-rays with additional distraction series in the operating room are sufficient in complete articular fracture cases. Partial intra-articular fractures will need CT scan and 3D reconstruction to fully evaluate the involved fragments. SOFCOT, AO/OTA and Dubberley classifications are the most useful for describing fractures and selecting treatment. Surgery is the optimal treatment and planning is based on fracture type. Complete fractures are treated using a posterior approach. Triceps management is a function of fracture lines and type of fixation planned. Constructs using two plates at 90° or 180° are the most stable, with additional frontal screw for intercondylar fractures. Elbow arthroplasty may be indicated in selected patients, having severely communited distal humerus fractures and osteoporotic bone. Open fractures make fixation and wound management more challenging and unfortunately have poorer outcomes. Other complications are elbow stiffness, non-union, malunion and heterotopic ossification.

[The distally based sural flap at the ankle and foot: complications analysis in a 27 cases study]. / 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.

Distally-based vastus lateralis muscle flap: a salvage alternative to address complex soft tissue defects around the knee.

Repeated soft tissue injuries around the knee represent challenging clinical situations where functional prognosis of the joint is often poor, especially in the presence of total knee arthroplasty (TKA). When gastrocnemius muscle flap techniques have already been used and failed, therapeutic solutions become rare. The authors suggest a regional solution to salvage these cases by the transfer of distally-based vastus lateralis muscle flaps. Four clinical operations of this muscle flap transfer are described, with three around TKA revision and one case of a post-traumatic knee amputation resulting from a compound open knee injury. Technical details of the intervention are presented. In all cases, skin closure was achieved, even if distal marginal necrosis was seen in two cases related to the type of muscle flap vascularisation.Final joint mobility was always poor (45 grades on average). Distally-based vastus lateralis muscle flaps represent a salvage procedure to correct iterative soft tissue defects around the knee that threaten short-term joint function. These muscle flaps do not require microsurgical anastomosis.

Synoviocyte infection with adeno-associated virus (AAV) is neutralized by human synovial fluid from arthritis patients and depends on AAV serotype.

Intraarticular gene transfer with adeno-associated viral (AAV) vectors may allow efficient therapeutic transgene expression within the joint in diseases such as rheumatoid arthritis (RA), allowing high expression of the protein within the joint, preventing both systemic diffusion and side effects. However, humans demonstrate antibodies against AAV, which can influence gene transfer. To better understand critical obstacles to intraarticular gene therapy with AAV, we have previously shown that synovial fluid (SF) contains IgG to AAV that neutralizes chondrocyte infection in vitro. Our objective was therefore to compare neutralization exerted by SF from RA patients for four different AAV serotypes (AAV serotypes 1, 2, 5, and 8) on human primary synoviocytes. Serotype 2 infected synoviocytes most efficiently followed, in decreasing order, by serotypes 1, 5, and 8. SF from all patients partially inhibited infection of synoviocytes by at least one of the four serotypes. Infection with serotypes 1 and 2 was the most inhibited by SF, whereas inhibition was weak for serotypes 5 and 8. Last, we have shown that inhibition of AAV1/interleukin (IL)-4 infection of synoviocytes by SF could be reversed by increasing the number of AAV1/IL-4 particles, with a dose-dependent effect. We conclude that the most infectious AAV serotypes (1 and 2) in synoviocytes are also the serotypes most neutralized by SF. Thus, serotype 5 seems to demonstrate the best infection efficiency:immunogenicity ratio for local use in articular diseases. These data may be useful for tailoring intraarticular AAV-mediated gene therapy to individual patients.

[Giant-cell tumor of the hand: midterm results in five patients]. / Tumeur à cellules géantes de la main: résultats du traitement: 5 cas au recul moyen de 7, 8 ans.

PURPOSE OF THE STUDY: Giant-cell bone tumors are benign but have great potential for recurrence. Frequently observed in epiphyseal areas of tubular bones, these tumors are rarely found in hand localizations. We examined the characteristic features of giant-cell tumors of the hand and analyzed the pertinence of surgical treatment. We noted complications, consequences of recurrence and later operations on the same tumor site in five cases. CASE REPORTS: Five patients treated between 1973 and 2000 for giant-cell tumors involving the hand bones were reviewed retrospectively. Mean age was 41.6 years and mean follow-up was 7.8 years. The surgical procedure was curettage for two, curettage with bone graft for two and amputation for one. The Enneking score was noted. RESULTS: Pain was the main symptom, with local swelling in several cases. At 7.8 years follow-up recurrence was noted for four of the five tumors. Two patients were treated for a second recurrence. Amputation of the forearm was required for one recurrence affecting soft tissue. Mean time between two consecutive recurrences was three months. In all six episodes of recurrent tumor were treated. These five patients had a total of ten operations. There were no cases of metastasis nor multicentric foci. DISCUSSION: Treatment of giant-cell tumors involving the hand bones is designed to eradicate the tumor and also protect hand function while keeping in mind the aggressive nature of these benign tumors. Surgical alternatives for radical treatment can include wide resection, resection of the ray and amputation.

[Bilateral fracture of the pisiform bone]. / Fracture bilatérale de l'os pisiforme.

Fracture of the pisiform bone is exceptional compared with the other carpal bones. Such lesions may be missed in the emergency room because of the complex anatomy of the carpal region. The usual circumstances leading to fracture of the pisiform bone include fall with reception on the hyperextended wrist, traffic accidents, and blunt trauma. The purpose of this work was to present a case of bilateral fracture of the pisiform bones. A 34-year-old woman presented with pain along the ulnar borders of both wrists after a fall. The mechanism of fracture was direct trauma on both hands after reception in radial inclination. The diagnosis was established late and conservative treatment was applied. After simple immobilization, the clinical and functional outcome was excellent. The anatomic position of the pisiform bone exposes it to direct trauma. Late diagnosis can favor osteoarthritic sequelae involving the pisotriquetral joint.

Septocutaneous perforators of the peroneal artery relative to the fibula: anatomical basis of the use of pedicled fasciocutaneous flap.

There are many studies describing the perforating branches of the peroneal artery but none of them identifies their locations relative to fibula. The aim of this study was to demonstrate the locations of the perforators relative to the fibula and to present a case, treated with an adipofascial flap, based on one of these small arteries. In this study, nine fresh male cadavers' legs injected with colored latex were dissected for demonstration of the longitudinal axis of these perforators. A large incision was made on the lateral part of the leg from the head of the fibula to the ankle. The peroneal perforating vessels were displayed. The posterior margin of the fibula was marked with needles from proximal to distal just above every perforator. The distance between the needle and the perforator was recorded. Their diameters were measured at the level of fascial emergence. There were four to seven perforating vessels; the larger vessels were near the proximal end of the fibula with an average of 1.1 mm and a minimum of 0.8 mm. We found that these branches were not parallel to fibula, but aligned in an oblique projection from posterior to anterior and from distal to proximal because of the course of the intermuscular septum between the soleus and peroneus longus muscles. The lowermost vessel was 1.7 cm away from the posterior margin of the fibula while the uppermost vessel was 0.25 cm away from the posterior ridge of the fibula. Adipofascial or fasciocutaneous flaps, which have important advantages in covering small to medium sized defects, can be based on the perforators of the peroneal artery. But for the centralization of the flap pedicle, the locations of the perforators, which are aligned from the lateral malleolus to the fibular head in oblique direction and from the posterior to the anterior must be taken into consideration. This knowledge is crucial for the flap design and the centralization of the vessels.

[Pre-operative diagnosis of bucket-handle meniscal tears: clinical evaluation and value of arthroscan and MRI radiological criteria]. / Diagnostic préopératoire des anses de seau méniscales: valeur des critères cliniques, arthro-TDM et IRM.

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.

[Prospective study assessing quality-of-life after hemiarthroplasty for hip fracture]. / Morbidité, mortalité et autonomie des patients opérés par prothèse intermédiaire pour fracture cervicale vraie.

PURPOSE OF THE STUDY: We conducted a prospective multicentric study of 203 consecutive patients who underwent hemi-arthroplasty for femoral neck fracture between May 1999 and August 2001. The purpose of the study was to assess quality-of-life among these patients one year after their surgery. MATERIAL AND METHODS: Mean patient age was 79.6 +/- 8.6 years; 71.2% were women. Most fractures were Garden type III and IV (87.4%) and 90.9% were recent (< 21 d). The hemiarthroplasty was performed with the Intermedia implant via a posterolateral approach in 73.9% of patients with acetabular reaming for 13.7%; a skirted head was used in only 20.8%. The Robinson score (19/26 < or = 6.89) for joint motion, lifestyle, degree of osteoporosis (Singh score), and history (ASA score), as well as a psychomotor indicator (Hodkinson score) were noted preoperatively. Quality-of-life was measured at one year in the same patients using the Postel Merle d'Aubigne (PMA) score and a quality-of-life score. RESULTS: Among the 203 patients, 38 (18.7%) were lost to follow-up and 37 died (18.2%). Eleven posterior dislocations (5.4%) were noted and four were reduced orthopedically. The PMA score was 84.7% satisfactory results (excellent, very good, good). Preoperatively 58.8% of the patients were independent and 7% were in nursing homes; one year postoperatively, these proportions were 54% and 4.8%. There was a significant difference in the PMA score between two populations defined by the preoperative Robinson score less than or greater than 20. Outcome was better for patients with a Robinson score > 20 pre-operatively. For these two populations, change in lifestyle was highly significant one year postoperatively. However, for the overall population, changes in lifestyle and joint motion were not significantly different between the pre- and postoperative evaluations. Paradoxically, 29.1% of the patients who were dependent preoperatively were not one year after surgery, which indicates that certain patients also had a better quality-of-life after their hemiarthroplasty. CONCLUSION: Mortality after fracture of the femoral neck remains high (18.2% at one year). There were no infections requiring revision in this series, but there were eleven cases of dislocation (5.4%). The difference in joint motion and quality-of-life between the pre- and postoperative assessment was not significant for the whole population, but one third of the patients who were independent preoperatively were not at last follow-up.