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1.
Eur J Surg Oncol ; 46(8): 1415-1422, 2020 08.
Article in English | MEDLINE | ID: mdl-32402509

ABSTRACT

OBJECTIVE: Aim of the manuscript is to discuss how to improve margins in sacral chordoma. BACKGROUND: Chordoma is a rare neoplasm, arising in half cases from the sacrum, with reported local failure in >50% after surgery. METHODS: A multidisciplinary meeting of the "Chordoma Global Consensus Group" was held in Milan in 2017, focusing on challenges in defining and achieving optimal margins in chordoma with respect to surgery, definitive particle radiation therapy (RT) and medical therapies. This review aims to report on the outcome of the consensus meeting and to provide a summary of the most recent evidence in this field. Possible new ways forward, including on-going international clinical studies, are discussed. RESULTS: En-bloc tumor-sacrum resection is the cornerstone of treatment of primary sacral chordoma, aiming to achieve negative microscopic margins. Radical definitive particle therapy seems to offer a similar outcome compared to surgery, although confirmation in comparative trials is lacking; besides there is still a certain degree of technical variability across institutions, corresponding to different fields of treatment and different tumor coverage. To address some of these questions, a prospective, randomized international study comparing surgery versus definitive high-dose RT is ongoing. Available data do not support the routine use of any medical therapy as (neo)adjuvant/cytoreductive treatment. CONCLUSION: Given the significant influence of margins status on local control in patients with primary localized sacral chordoma, the clear definition of adequate margins and a standard local approach across institutions for both surgery and particle RT is vital for improving the management of these patients.


Subject(s)
Chordoma/radiotherapy , Chordoma/surgery , Margins of Excision , Sacrum/surgery , Humans , Proton Therapy/adverse effects , Radiotherapy Dosage
2.
Anaesth Crit Care Pain Med ; 39(2): 279-289, 2020 04.
Article in English | MEDLINE | ID: mdl-32229270

ABSTRACT

OBJECTIVES: To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury. DESIGN: A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS: The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology. RESULTS: The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. CONCLUSIONS: There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.


Subject(s)
Intubation, Intratracheal , Spinal Cord Injuries , France , Humans , Respiration, Artificial , Resuscitation , Spinal Cord Injuries/therapy
3.
Support Care Cancer ; 28(5): 2127-2135, 2020 May.
Article in English | MEDLINE | ID: mdl-31396747

ABSTRACT

BACKGROUND: Owing to recent advances in cancer therapy, updated data are required for clinicians counselling patients on treatment of spinal metastases. OBJECTIVE: To analyse the outcomes of surgical treatments of spinal metastases. METHODS: Prospective and multicentric study that included consecutively patients operated on for spinal metastases between January 2016 and January 2017. Overall survival was calculated with the Kaplan-Meier method. Cox proportional hazard model was used to calculate hazard ratio (HR) analysing mortality risk according to preoperative Karnofsky performance status (KPS), mobility level and neurological status. RESULTS: A total of 252 patients were included (145 males, 107 females) aged a mean 63.3 years. Median survival was 450 days. Primary cancer sites were lung (21%) and breast (19%). Multiple spinal metastases involved 122 patients (48%). Concomitant skeletal and visceral metastases were noted in 90 patients (36%). Main procedure was laminectomy and posterior fixation (57%). Overall, pain and mobility level were improved postoperatively. Most patients had normal preoperative motor function (50%) and remained so postoperatively. Patients "bedbound" on admission were the less likely to recover. In-hospital death rate was 2.4% (three disease progression, one septic shock, one pneumonia, one pulmonary embolism). Complication rate was 33%, deep wound infection was the most frequent aetiology. Higher mortality was observed in patients with poorest preoperative KPS (KPS 0-40%, HR = 3.1, p < 0.001) and mobility level ("bedbound", HR = 2.16, p < 0.001). Survival seemed also to be linked to preoperative neurological function. CONCLUSION: Surgical treatments helped maintain reasonable condition for patients with spinal metastases. Intervention should be offered before patients' condition worsen to ensure better outcomes.


Subject(s)
Pain Management/methods , Spinal Neoplasms/secondary , Spinal Neoplasms/surgery , Aged , Breast Neoplasms/pathology , Disease Progression , Female , Humans , Karnofsky Performance Status , Lung Neoplasms/pathology , Male , Middle Aged , Neoplasm Recurrence, Local/pathology , Pain/complications , Proportional Hazards Models , Prospective Studies , Retrospective Studies , Spinal Neoplasms/mortality , Spine/pathology , Survival Rate , Treatment Outcome
5.
Orthop Traumatol Surg Res ; 104(1S): S31-S40, 2018 02.
Article in English | MEDLINE | ID: mdl-29225115

ABSTRACT

Thoracic disc herniation is rare and mainly occurs between T8 and L1. The herniation is calcified in 40% of cases and is labeled as giant when it occupies more than 40% of the spinal canal. A surgical procedure is indicated when the patient has severe back pain, stubborn intercostal neuralgia or neurological deficits. Selection of the surgical approach is essential. Mid-line calcified hernias are approached from a transthoracic incision, while lateralized soft hernias can be approached from a posterolateral incision. The complication rate for transthoracic approaches is higher than that of posterolateral approaches; however, the former are performed in more complex herniation cases. The thoracoscopic approach is less invasive but has a lengthy learning curve. Retropleural mini-thoracotomy is a potential compromise solution. Fusion is recommended in cases of multilevel herniation, herniation in the context of Scheuermann's disease, when more than 50% bone is resected from the vertebral body, in patients with preoperative back pain or herniation at the thoracolumbar junction. Along with complications specific to the surgical approach, the surgical risks are neurological worsening, dural breach and subarachnoid-pleural fistulas. Giant calcified herniated discs are the largest contributor to myelopathy, intradural extension and postoperative complications. Some of the technical means that can be used to prevent complications are explored, along with how to address these complications.


Subject(s)
Diskectomy/adverse effects , Diskectomy/methods , Intervertebral Disc Displacement/surgery , Thoracic Vertebrae , Back Pain/etiology , Calcinosis/complications , Calcinosis/surgery , Humans , Intervertebral Disc Displacement/complications , Intervertebral Disc Displacement/diagnostic imaging , Intervertebral Disc Displacement/epidemiology , Neuralgia/etiology , Patient Selection , Spinal Cord Diseases/etiology
6.
Orthop Traumatol Surg Res ; 103(8): 1169-1171, 2017 12.
Article in English | MEDLINE | ID: mdl-28964921

ABSTRACT

Several posterior fixation techniques for unstable pelvic ring fractures have been described. Here, we present a minimally invasive, percutaneous technique to fix the two posterior iliac crests using spinal instrumentation. Between September 2008 and March 2012, 11 patients with a mean age of 36.4 years were operated because of a vertically unstable Tile C pelvic ring fracture. Posterior fixation was performed using two polyaxial screws in each iliac crest with two subfascial connector rods. At the final follow-up, all patients were evaluated clinically and radiologically. The mean surgery time was 45 minutes; there were no intraoperative complications. At a mean follow-up of four years, the functional Majeed score was excellent in eight patients and good in three patients. The radiological results were excellent in eight patients and good in three patients. Percutaneous posterior fixation of vertically unstable pelvic fractures leads to good functional and radiological outcomes. TYPE OF STUDY: Technical note, retrospective. LEVEL OF EVIDENCE: IV.


Subject(s)
Fracture Fixation, Internal/methods , Fractures, Bone/surgery , Ilium/injuries , Ilium/surgery , Adolescent , Adult , Aged , Bone Screws , Female , Follow-Up Studies , Fracture Fixation, Internal/instrumentation , Fractures, Bone/diagnostic imaging , Humans , Ilium/diagnostic imaging , Male , Middle Aged , Minimally Invasive Surgical Procedures/methods , Operative Time , Radiography , Retrospective Studies , Young Adult
7.
Orthop Traumatol Surg Res ; 103(1S): S83-S90, 2017 02.
Article in English | MEDLINE | ID: mdl-28057478

ABSTRACT

Under the new categorization introduced by the Health Authorities, ambulatory surgery (AS) in France now accounts for 50% of procedures, taking all surgical specialties together. The replacement of full hospital admission by AS is now well established and recognized. Health-care centers have learned, in coordination with the medico-surgical and paramedical teams, how to set up AS units and the corresponding clinical pathways. There is no single model handed down from above. The authorities have encouraged these developments, partly by regulations but also by means of financial incentives. Patient eligibility and psychosocial criteria are crucial determining factors for the success of the AS strategy. The surgeons involved are strongly committed. Feedback from many orthopedic subspecialties (shoulder, foot, knee, spine, hand, large joints, emergency and pediatric surgery) testify to the rise of AS, which now accounts for 41% of all orthopedic procedures. Questions remain, however, concerning the role of the GP in the continuity of care, the role of innovation and teaching, the creation of new jobs, and the attractiveness of AS for surgeons. More than ever, it is the patient who is "ambulatory", within an organized structure in which surgical technique and pain management are well controlled. Not all patients can be eligible, but the AS concept is becoming standard, and overnight stay will become a matter for medical and surgical prescription.


Subject(s)
Ambulatory Surgical Procedures/statistics & numerical data , Orthopedic Procedures/statistics & numerical data , Orthopedics/organization & administration , Trauma Centers/organization & administration , France , Humans
8.
Neurochirurgie ; 63(5): 419-425, 2017 Nov.
Article in French | MEDLINE | ID: mdl-27211059

ABSTRACT

INTRODUCTION: Spinal deformity following surgery for intramedullary tumors is a serious potential complication. The aim of the study was to identify potential predictive risk factors of spinal deformity after intramedullary tumor surgery. MATERIAL AND METHODS: Retrospective study including patients harboring intramedullary tumors who underwent surgery in a single center (Hôpital Bicêtre, AP-HP, Paris) between 1985 and 2011. The main outcome was the difference at last follow-up between post- and preoperative measure of Cobb angles formed by the superior and inferior limits of the laminectomy (Δ_Cobb). RESULTS: Sixty-three patients included. Mean sagittal deformity was 15.9° (0°-77°) for a mean follow-up of 85 months (4-240). Univariate analysis of potential predictive factors showed an increased deformity for patients undergoing a 4-or-more levels laminectomy, (19.3° versus 12.1°; P=0.04), for patients aged less or equal to 30 years of age and when it included a junction (20.8° versus 12.4°; P=0.02). A neurological deficit, either pre- or postoperatively, was not associated with a greater deformity. Multivariate analysis showed that only age (P=0.01) and the number of spinal levels involved (P=0.014) were significant and independent predictors of postoperative deformity. CONCLUSION: This study indicates predictive factors of spinal deformity in any patient undergoing surgery for intramedullary tumors, allowing improvement in the planning of surgery and patients' follow-up.


Subject(s)
Laminectomy/adverse effects , Spinal Cord Neoplasms/surgery , Humans , Prognosis , Retrospective Studies , Risk Factors , Spinal Cord Neoplasms/diagnostic imaging , Spinal Diseases/diagnostic imaging , Spinal Diseases/etiology
9.
Br J Cancer ; 114(12): 1367-75, 2016 06 14.
Article in English | MEDLINE | ID: mdl-27300108

ABSTRACT

BACKGROUND: Current diagnosis and staging of pancreatic ductal adenocarcinoma (PDAC) has important limitations and better biomarkers are needed to guide initial therapy. We investigated the performance of circulating tumour cells (CTCs) as an adjunctive biomarker at the time of disease presentation. METHODS: Venous blood (VB) was collected prospectively from 100 consecutive, pre-treatment patients with PDAC. Utilising the microfluidic NanoVelcro CTC chip, samples were evaluated for the presence and number of CTCs. KRAS mutation analysis was used to compare the CTCs with primary tumour tissue. CTC enumeration data was then evaluated as a diagnostic and staging biomarker in the setting of PDAC. RESULTS: We found 100% concordance for KRAS mutation subtype between primary tumour and CTCs in all five patients tested. Evaluation of CTCs as a diagnostic revealed the presence of CTCs in 54/72 patients with confirmed PDAC (sensitivity=75.0%, specificity=96.4%, area under the curve (AUROC)=0.867, 95% CI=0.798-0.935, and P<0.001). Furthermore, a cut-off of ⩾3 CTCs in 4 ml VB was able to discriminate between local/regional and metastatic disease (AUROC=0.885; 95% CI=0.800-0.969; and P<0.001). CONCLUSION: CTCs appear to function well as a biomarker for diagnosis and staging in PDAC.


Subject(s)
Carcinoma, Pancreatic Ductal/pathology , Neoplastic Cells, Circulating/pathology , Pancreatic Neoplasms/pathology , Biomarkers, Tumor/blood , Carcinoma, Pancreatic Ductal/blood , Cohort Studies , Humans , Neoplasm Staging , Pancreatic Neoplasms/blood , Proto-Oncogene Proteins p21(ras)/genetics
10.
Orthop Traumatol Surg Res ; 102(1): 121-5, 2016 Feb.
Article in English | MEDLINE | ID: mdl-26796999

ABSTRACT

UNLABELLED: Sacral chordoma (SC) is a malignant bone tumor with high risk of local recurrence (LR) even after en bloc resection, generally in the first 10 years after resection. We report two cases of late LR, at 17 and 19 years. Two male patients, aged 45 and 53 years, presented with large SC needing a combined approach for en bloc resection. Surgical margins were safe for the first patient and borderline for the second. The patients had yearly follow-up. The first patient developed LR on the posterior wall of the right acetabulum and the second developed LR in the right sciatic notch, at 17 and 19 years, respectively. These two cases of very late LR of SC advocate for yearly screening of patients even more than 20 years after resection. LEVEL OF EVIDENCE: IV (case report).


Subject(s)
Chordoma/surgery , Neoplasm Recurrence, Local/surgery , Sacrum/surgery , Spinal Neoplasms/surgery , Arthroplasty, Replacement, Hip , Chordoma/pathology , Humans , Magnetic Resonance Imaging , Male , Middle Aged , Neoplasm Recurrence, Local/pathology , Sacrum/pathology , Spinal Neoplasms/pathology
11.
Orthop Traumatol Surg Res ; 100(8): 873-7, 2014 Dec.
Article in English | MEDLINE | ID: mdl-25453913

ABSTRACT

BACKGROUND: Unicondylar fractures of the distal femur are rare, complex, intra-articular fractures. The objective of this multicentre study was to assess the reduction and fixation of unicondylar fractures. HYPOTHESIS: Anatomic reduction followed by strong fixation allows early rehabilitation therapy and provides good long-term outcomes. MATERIAL AND METHODS: We studied 163 fractures included in two multicentre studies, of which one was retrospective (n=134) and the other prospective (n=29). Follow-up of at least 1 year was required for inclusion. The treatment was at the discretion of the surgeon. Outcome measures were the clinical results assessed using the International Knee Society (IKS) scores and presence after fracture healing of malunion with angulation, an articular surface step-off, and/or tibio-femoral malalignment. RESULTS: Mean age of the study patients was 50.9 ± 24 years, and most patients were males with no previous history of knee disorders. The fracture was due to a high-energy trauma in 51% of cases; 17% of patients had compound fractures and 44% multiple fractures or injuries. The lateral and medial condyles were equally affected. The fracture line was sagittal in 82% of cases and coronal (Hoffa fracture) in 18% of cases. Non-operative treatment was used in 5% of cases and internal fixation in 95% of cases, with either direct screw or buttress-plate fixation for the sagittal fractures and either direct or indirect screw fixation for the coronal fractures. After treatment of the fracture, 15% of patients had articular malunion due to insufficient reduction, with either valgus-varus (10%) or flexion-recurvatum (5%) deformity; and 12% of patients had an articular step-off visible on the antero-posterior or lateral radiograph. Rehabilitation therapy was started immediately in 65% of patients. Time to full weight bearing was 90 days and time to fracture healing 120 days. Complications consisted of disassembly of the construct (2%), avascular necrosis of the condyle (2%), and arthrolysis (5%). The material was removed in 11% of patients. At last follow-up, the IKS knee score was 71 ± 20 and the IKS function score 64 ± 7; flexion range was 106 ± 28° (<90° in 27% of patients); and 12% of patients had knee osteoarthritis. CONCLUSION: Anatomic reduction of unicondylar distal femoral fractures via an appropriate surgical approach, followed by stable internal fixation using either multiple large-diameter screws or a buttress-plate, allows immediate mobilisation, which in turn ensures good long-term outcomes. LEVEL OF EVIDENCE: IV, cohort study.


Subject(s)
Bone Plates , Bone Screws , Femoral Fractures/surgery , Fracture Fixation, Internal/methods , Adolescent , Adult , Aged , Aged, 80 and over , Cohort Studies , Female , Femoral Fractures/diagnostic imaging , Fracture Healing , France , Humans , Male , Middle Aged , Prospective Studies , Radiography , Range of Motion, Articular , Retrospective Studies
12.
Orthop Traumatol Surg Res ; 98(8): 900-9, 2012 Dec.
Article in English | MEDLINE | ID: mdl-23165222

ABSTRACT

Numerous improvements in minimally invasive spine surgery (MISS) have been made during the last decade. MISS in thoracolumbar spine trauma management must achieve the same results as conventional treatment but with less morbidity. The increased use of MISS technologies in spine trauma has been correlated to the availability of more versatile instrumentation, which makes the fixation of all thoracic and lumbar levels possible. Balloon-assisted techniques have been used to support the anterior column in a stand-alone manner or in combination with open or percutaneous pedicle screw fixation. Fluoroscopy-assisted pedicle screw insertion is associated with less pedicle wall violation when compared to open surgery, but with increased radiation exposure for the surgeon and patient. Surgeons must be aware of this issue and new technologies are available to decrease irradiation. The advantages of percutaneous pedicle screw fixation relative to open surgery are discussed: preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter rehabilitation time as well as shorter hospital stay. Limitations of percutaneous fixation include the inability to achieve direct spinal canal decompression and not having the option to perform a fusion. Nevertheless, these limitations can be addressed by combining MISS with open techniques. Indications for percutaneous spine fixation alone or in combination with MISS or open techniques are discussed based on the AO classification. The benefits of percutaneous spinal fixation for unstable spine fractures in polytrauma patients are also discussed. Posterior instrumentation can be easily removed after bone union to allow young patients to regain their mobility. Large well-controlled prospective studies are needed to draw up guidelines for less invasive procedures in spine trauma. In the future, development of new technologies can expand the scope of indications and treatment possibilities using MISS techniques in spine trauma.


Subject(s)
Fracture Fixation, Internal/methods , Lumbar Vertebrae/injuries , Lumbar Vertebrae/surgery , Multiple Trauma/surgery , Spinal Fractures/surgery , Thoracic Vertebrae/injuries , Thoracic Vertebrae/surgery , Humans
13.
Orthop Traumatol Surg Res ; 98(6 Suppl): S112-9, 2012 Oct.
Article in English | MEDLINE | ID: mdl-22939104

ABSTRACT

BACKGROUND: Osteoporotic spine fractures induce a heavy burden in terms of both general health and healthcare costs. The objective of this multicentre study by the French Society for Spine Surgery (SFCR) was to compare outcomes after vertebroplasty and kyphoplasty in the treatment of osteoporotic thoracolumbar vertebral fractures. HYPOTHESIS: We hypothesised that differences existed between vertebroplasty and kyphoplasty, notably regarding operative time and reduction efficacy, from which criteria for patient selection might be inferred. MATERIAL AND METHODS: We conducted a retrospective multicentre review of 127 patients with Magerl Type A low-energy fractures after a fall from standing height between 2007 and 2010; 85 were managed with vertebroplasty and 42 with kyphoplasty. Age was not a selection criterion. We recorded pain intensity, time to management, operative time, kyphosis angle, wedge angle, cement leakage rate, and degree of cement filling. RESULTS: Operative time was 43 minutes with kyphoplasty and 24 minutes with vertebroplasty (P=0.0002). Both techniques relieved pain, with no significant difference. Kyphoplasty significantly improved the wedge angle, by +6°, versus +2° with vertebroplasty (P=0.002). With kyphoplasty, the volume injected was larger and cement distribution was less favourable. Leakage rates were similar. DISCUSSION: Despite the heterogeneity of our study, our data confirm the effectiveness of kyphoplasty in alleviating pain and decreasing deformities due to osteoporotic vertebral fractures. Vertebroplasty is a faster and less costly procedure that remains useful; no detectable clinical complications occur with vertebroplasty, which ensures better anchoring of the cement in the cancellous bone.


Subject(s)
Lumbar Vertebrae/surgery , Osteoporotic Fractures/surgery , Spinal Fractures/surgery , Thoracic Vertebrae/surgery , Vertebroplasty/methods , Adult , Aged , Aged, 80 and over , Bone Density/physiology , Cohort Studies , Female , Follow-Up Studies , Fracture Healing/physiology , Humans , Kyphoplasty/adverse effects , Kyphoplasty/methods , Lumbar Vertebrae/diagnostic imaging , Male , Middle Aged , Minimally Invasive Surgical Procedures/methods , Operative Time , Osteoporotic Fractures/diagnostic imaging , Patient Positioning , Radiography , Retrospective Studies , Risk Assessment , Severity of Illness Index , Spinal Fractures/diagnostic imaging , Thoracic Vertebrae/diagnostic imaging , Time Factors , Treatment Outcome , Vertebroplasty/adverse effects
14.
Orthop Traumatol Surg Res ; 98(6 Suppl): S105-11, 2012 Oct.
Article in English | MEDLINE | ID: mdl-22901522

ABSTRACT

STUDY DESIGN: Retrospective review of prospectively collected data. BACKGROUND: There is no consensus regarding the ideal treatment of thoraco-lumbar spine fractures without neurological compromise. Many surgical techniques have been described but none has proved its definite superiority. The main drawback of these procedures is directly related to the morbidity of the approach. As minimally invasive fixation combined with balloon kyphoplasty for treatment of thoraco-lumbar fractures is gaining popularity, its efficacy has yet to be established. PURPOSE: The purpose of this study is to report operative data, clinical and radiological outcomes of patients undergoing minimally invasive management of thoraco-lumbar fracture at our institutions. METHODS: Forty-one patients underwent percutaneous kyphoplasty and stabilization for treatment of single-level fracture of the thoracic or lumbar spine. All patients were neurologically intact. There were 20 males and 21 females with an average age of 50 years. RESULTS: The mean follow-up was 15 months (3-90 months). The mean operative time was 102 minutes (range 35-240 minutes) and the mean blood loss was <100mL. VAS was significantly improved from 6.7 to 0.7 at last follow-up. Vertebral kyphosis decreased by 16° to 7.8° postoperatively (P<0.001). Local kyphosis and percentage of collapse were also significantly improved from 8° to 5.6° and from 35% to 16% at last follow-up. Fifteen leaks have been identified, three of which were posterior; all remained asymptomatic. No patient worsened his or her neurological condition postoperatively. CONCLUSION: Percutaneous stabilization plus balloon kyphoplasty seems to be a safe and effective technique to manage thoraco-lumbar fractures without neurological impairment.


Subject(s)
Lumbar Vertebrae/surgery , Spinal Fractures/surgery , Thoracic Vertebrae/surgery , Vertebroplasty/methods , Adult , Aged , Aged, 80 and over , Bone Screws , Cohort Studies , Combined Modality Therapy , Female , Follow-Up Studies , Fracture Fixation, Internal/instrumentation , Fracture Fixation, Internal/methods , Fracture Healing/physiology , Humans , Intraoperative Care/methods , Kyphoplasty/methods , Lumbar Vertebrae/injuries , Male , Middle Aged , Minimally Invasive Surgical Procedures/methods , Patient Positioning , Patient Safety , Radiography , Recovery of Function , Retrospective Studies , Risk Assessment , Spinal Fractures/diagnostic imaging , Thoracic Vertebrae/injuries , Time Factors , Treatment Outcome
15.
Orthop Traumatol Surg Res ; 97(4): 454-8, 2011 Jun.
Article in English | MEDLINE | ID: mdl-21549658

ABSTRACT

Blunt carotid injury associated with cervical spine fractures is a rare entity but potentially lethal. An initial, clinically silent period can be misleading. Prompt diagnosis and treatment are mandatory to avoid neurological damages and death. We present the case of a 36-year-old man diagnosed with an isolated cervical spine fracture, where an associated carotid artery lesion was initially overlooked and diagnosis was made after development of a neurological deterioration secondary to a posterior reversible encephalopathy syndrome (PRES). We discuss a simple algorithm that can be used to make the diagnosis, even during the clinically asymptomatic period of this injury.


Subject(s)
Carotid Artery Injuries/diagnostic imaging , Cervical Vertebrae/injuries , Magnetic Resonance Angiography/methods , Multiple Trauma/diagnostic imaging , Posterior Leukoencephalopathy Syndrome/diagnostic imaging , Spinal Fractures/diagnostic imaging , Accidents, Traffic , Adult , Carotid Artery Injuries/complications , Carotid Artery Injuries/surgery , Cervical Vertebrae/diagnostic imaging , Early Diagnosis , Follow-Up Studies , Glasgow Coma Scale , Humans , Injury Severity Score , Male , Multiple Trauma/surgery , Posterior Leukoencephalopathy Syndrome/complications , Posterior Leukoencephalopathy Syndrome/therapy , Rare Diseases , Risk Assessment , Spinal Fractures/complications , Spinal Fractures/surgery , Tomography, X-Ray Computed/methods , Treatment Outcome , Wounds, Nonpenetrating/complications , Wounds, Nonpenetrating/diagnostic imaging , Wounds, Nonpenetrating/surgery
16.
J Radiol ; 91(9 Pt 2): 1022-34, 2010 Sep.
Article in French | MEDLINE | ID: mdl-20814393

ABSTRACT

Some early complications (hematoma, spondylodiscitis, pseudomeningocele) can occur with all types of surgery while late complications vary with the type of surgery. After discectomy, postsurgical changes (osseous and ligamentous defects, scar tissue, granulation tissue) should be distinguished from postsurgical complications or recurrent disease (recurrent disc herniation, arachnoiditis, spondylodiscitis). Following spinal decompression and fusion procedures, standard radiographs and CT can confirm the adequate position of the fusion devices, the presence of fusion, and the development of late osseous complications: pseudarthrosis, instability and recurrent stenosis.


Subject(s)
Decompression, Surgical , Diskectomy , Image Processing, Computer-Assisted , Laminectomy , Lumbar Vertebrae/surgery , Magnetic Resonance Imaging , Postoperative Complications/diagnosis , Spinal Diseases/surgery , Spinal Fusion , Tomography, X-Ray Computed , Arteriovenous Fistula/diagnosis , Arteriovenous Fistula/etiology , Arteriovenous Fistula/surgery , Diagnosis, Differential , Female , Humans , Iliac Artery/injuries , Iliac Vein/injuries , Lumbar Vertebrae/pathology , Middle Aged , Pain, Postoperative/diagnosis , Pain, Postoperative/etiology , Pain, Postoperative/surgery , Postoperative Hemorrhage/diagnosis , Postoperative Hemorrhage/etiology , Postoperative Hemorrhage/surgery , Recurrence , Reoperation , Sensitivity and Specificity , Surgical Wound Infection/diagnosis , Surgical Wound Infection/etiology , Surgical Wound Infection/surgery
17.
Orthop Traumatol Surg Res ; 95(4): 272-7, 2009 Jun.
Article in English | MEDLINE | ID: mdl-19473904

ABSTRACT

INTRODUCTION: Knee arthrodesis may be the last possible option for infected total knee arthroplasty (TKA) patients and in revision cases involving severe bone loss and/or extensor mechanism damages. Success in these situations depends on achieving good fixation assembly stability. We report bone fusion results using a fixation technique combining cross-pinning by two Steinman pins with a single-frame external fixator. Remission of infection at long-term follow-up was an additional criteria assessed for those cases initially treated for sepsis. HYPOTHESIS: This fixation modality improves fusion rates. PATIENTS AND METHODS: In six of this series of eight patients (mean age: 59 years), surgery was performed in a context of infection: five cases of infected TKA, and one case of septic arthritis. In the other two cases, arthrodesis was respectively indicated for a severe post-traumatic stiffness compounded by extensor system rupture and for a fracture combined to a complete mechanical implant loosening. In three of the six infection cases, arthrodesis was performed as a single-stage procedure. All patients were operated on using the same technique: primary arthrodesis site stabilization by frontal cross-pinning with two Steinman pins, followed by installation of a sagittal external fixator frame. Results were assessed at a mean 8 year follow-up. RESULTS: All the arthrodeses showed fusion at a mean 3.5 months (range: 2.5 to 6 months) postoperative delay without reintervention. Weight-bearing was resumed at 2 to 3 months. The external fixator was removed at a mean 5.2 months. No recurrence of infection was observed over a mean follow-up of 8.2 years (range: 1 to 15 years). Three complications occurred: one hematoma, managed surgically; one supracondylar fracture treated orthopedically; and one osteitis, managed by surgical curettage. DISCUSSION: This knee arthrodesis technique proved effective, with no failures in this short series, especially in cases of primary infection. It is a reproducible means of osteosynthesis, with little subsequent morbidity. Fixation in two orthogonal planes seemed to provide the stability required to achieve bone fusion. This assembly avoids internal fixation, which is never risk-free in a context of primary sepsis. LEVEL OF EVIDENCE: Level IV. Retrospective study.


Subject(s)
Arthritis, Infectious/surgery , Arthrodesis/methods , Arthroplasty, Replacement, Knee , Bone Nails , External Fixators , Knee Joint/surgery , Postoperative Complications/surgery , Prosthesis-Related Infections/surgery , Female , Follow-Up Studies , Hematoma/surgery , Hip Fractures/surgery , Humans , Knee Prosthesis , Male , Middle Aged , Osteitis/surgery , Prosthesis Failure , Treatment Outcome , Weight-Bearing
18.
Rev Chir Orthop Reparatrice Appar Mot ; 94 Suppl(6): S108-32, 2008 Oct.
Article in French | MEDLINE | ID: mdl-18928798

ABSTRACT

INTRODUCTION: Despite many papers and instructional course lectures, therapeutic guidelines are not clearly defined about treatment of femoral neck fractures. The aim of this multicentric French symposium was to prospectively study the results of current therapeutic options in order to propose scientifically proven options. MATERIAL AND METHODS: Three prospective studies were carried out in order to answer to these questions: (1) is it possible with anatomical reduction and stable fixation to lower the non union and osteonecrosis rate? (2) is functional treatment of Garden 1 fractures successful in more than 65 years patients? (3) what criteria are useful to choose the kind of arthroplasty for more than 65 years patients? RESULTS: For the 64 patients between 50 and 65 years old included in the first study, 44 ORIF and 17 prostheses were performed. No open reduction was performed in this series despite a 34% malreduction rate. The risk for displacement after functional treatment of Garden 1 fractures is 31%. For patients over 65 years old, almost fractures are treated in this series by an arthroplasty. The one-year mortality rate after displaced femoral neck fracture was 17%. Functional results were better in total hip prosthesis group than in bipolar or unipolar group. Non cemented stems were not safer than cemented ones in frail patients. DISCUSSION AND CONCLUSIONS: For young patients, ORIF should be the treatment of choice: the initial displacement and its effects on the femoral head vascularisation, the quality of reduction and fixation are the two most significant factors for good outcome. For Garden 1, fractures in patients 65 years old or more, it is proposed to performed an internal fixation despite in two thirds of the cases, it should be unnecessary because non identification of predictive factors of failure. For patients over 65 years old, the type of arthroplasty to perform in displaced fractures is to be chosen according to the preoperative mobility and comorbidities. Because of acetabular erosion with long-term follow-up, it is clearly indicated to perform total hip replacement for patients with life expectancy of 10 years or more. For frail patients, unipolar arthroplasty is the best option. The place for bipolar or uncemented implants is not yet well-defined and more prospective trials are needed. In this multicentric study, results appear quite different in terms of mortality, or functional status. These differences seem to be related to technical choice, geriatric care, nutritional consideration or surgical organisation, all factors that may be of major importance for prognostic.


Subject(s)
Arthroplasty, Replacement, Hip , Femoral Neck Fractures/surgery , Fracture Fixation, Internal , Hip Prosthesis , Age Factors , Aged , Aged, 80 and over , Female , Femoral Neck Fractures/mortality , Fractures, Ununited/prevention & control , Humans , Male , Osteonecrosis/prevention & control , Postoperative Complications , Prognosis , Prospective Studies , Risk Factors , Treatment Outcome
20.
Eur J Pain ; 12(8): 961-9, 2008 Nov.
Article in English | MEDLINE | ID: mdl-18304848

ABSTRACT

Research on massage therapy for maternal pain and anxiety in labour is currently limited to four small trials. Each used different massage techniques, at different frequencies and durations, and relaxation techniques were included in three trials. Given the need to investigate massage interventions that complement maternal neurophysiological adaptations to labour and birth pain(s), we designed a pilot randomised controlled trial (RCT) to test the effects of a massage programme practised during physiological changes in pain threshold, from late pregnancy to birth, on women's reported pain, measured by a visual analogue scale (VAS) at 90 min following birth. To control for the potential bias of the possible effects of support offered within preparation for the intervention group, the study included 3 arms--intervention (massage programme with relaxation techniques), placebo (music with relaxation techniques) and control (usual care). The placebo offered a non-pharmacological coping strategy, to ensure that use of massage was the only difference between intervention and placebo groups. There was a trend towards slightly lower mean pain scores in the intervention group but these differences were not statistically significant. No differences were found in use of pharmacological analgesia, need for augmentation or mode of delivery. There was a trend towards more positive views of labour preparedness and sense of control in the intervention and placebo groups, compared with the control group. These findings suggest that regular massage with relaxation techniques from late pregnancy to birth is an acceptable coping strategy that merits a large trial with sufficient power to detect differences in reported pain as a primary outcome measure.


Subject(s)
Analgesia/methods , Analgesia/psychology , Labor Pain/psychology , Labor Pain/therapy , Massage/trends , Music Therapy/trends , Adaptation, Psychological/physiology , Adolescent , Adult , Analgesia/statistics & numerical data , Female , Humans , Massage/standards , Massage/statistics & numerical data , Music Therapy/standards , Music Therapy/statistics & numerical data , Pain Measurement/methods , Pain Threshold/physiology , Pain Threshold/psychology , Patient Satisfaction , Pilot Projects , Placebo Effect , Placebos , Pregnancy , Relaxation Therapy/standards , Relaxation Therapy/statistics & numerical data , Relaxation Therapy/trends , Treatment Outcome
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