Survey of practices in surgical management of trapeziometacarpal osteoarthritis in France in 2020.

The purpose of this study was to obtain an overview of French surgical practices for treating trapeziometacarpal osteoarthritis in 2020. An online survey was sent to 64 French hand surgeons: 32 authors of articles on carpometacarpal osteoarthritis of the thumb and 32 other surgeons randomly selected from the membership of the French Society of Hand Surgery (SFCM). The questions concerned demographic data, surgical practice, operative indications, choices for revision surgery, and eight clinical cases. The response rate was 56.2%. The most popular technique was trapeziometacarpal replacement (63.9%). During the previous 5 years, 31.6% of respondents had changed their practices, 69.2% of whom had adopted total joint replacement. Total trapeziectomy with ligamentoplasty and interposition was the second most frequent method. Most surgeons (77.8%) implemented medical treatment for 6 months to 1 year before resorting to surgery. In the clinical cases, agreement between surgeons was very low, with an overall inter-rater concordance coefficient of 0.182. Except for two cases (a young manual worker and a patient with a flattened trapezium) where no technique was significantly preferred, trapeziometacarpal replacement was chosen by a majority of respondents (p < 0.001). It was the most frequently performed surgical technique in France in 2020. However, there is no real consensus on choice of technique, which reflects the absence of guidelines.

Tiny but risky: The reasons why the Caspar pin distractor causes suffocating cervical hematoma-Two cases and a literature review.

Symptomatic cervical hematoma (CH) after cervical spine surgery through an anterolateral approach is a feared complication. In up to 60% of CH cases, no source of bleeding is detected during drainage. Bleeding from the pin holes of the Caspar distractor is a known complication, briefly mentioned in the patent, but harmfulness has never been thoroughly assessed. Our team experienced two consecutive postoperative acute CHs, in which the origin of active bleeding obviously came from pin holes, despite careful obturation. The aim of this study was to report these two cases and provide a comprehensive assessment of the dangers of Caspar pin distractors. The intrabody vascularization was well organized and there was a central pedicle arising from the center of the posterior wall. The pedicle penetrated deeply into the body and constituted Batson's channel posteriorly. Retrospectively, it was well-identified in both cases on preoperative imaging. Given the morphological features of the vertebral cervical bodies and Caspar pin, the pin may reach the center of the posterior wall where the pedicle arises. Comparison between vertebral body volumes and the volume of the screwable part of the pins revealed that the pin could occupy up to 7.3% of the total body if randomly inserted. However, pins are in fact inserted into a particular place that contains the pedicle. Epidural bleeding is variable and may be undetected before closure. This also depends on blood pressure variations and changes in the patient's position. Even though Caspar pins are tiny, the likelihood of intrabody vascularization damage appears to be significant. Caspar pins should not be used systematically. Pin hole obturation must be solid and deep. Alternative options such as an interbody distractor and a microscope for the discectomy should be considered.

Restricted access to innovative surgical technique related to a specific training, is it ethical? Example of the PIPAC procedure. A systematic review and an experts survey.

OBJECTIVE: Using the example of Pressurized Intra Peritoneal Aerosol Chemotherapy (PIPAC), we analyse the development model of this procedure and provide an ethical analysis of the involvement of the industry in a new development. SUMMARY BACKGROUND DATA: In the case of breakthrough innovation, medical training is essential for safe use of the new procedure. In some cases, pharmaceutical companies decide to organise this training. But when it becomes the only training opportunity to use the device, scientists and clinicians could be exposed to a conflict of interest? METHODS: We performed a literature review of PIPAC publications using the STROBE criteria. Then, we conducted interviews with an expert panel to analyse the ethical impact of involvement of the industry in the development of the PIPAC procedure. RESULTS: The number of publications has increased every year since the first publication in Germany, where the technology was developed in 2013. The scientific production was of good quality, with a mean STROBE score of 18.2 ± 2.4 out of 22 points. Ten of the 33 included studies declared a conflict of interest. From the interviews, the main axe concerning the implication of the industry was the training model. The company had decided that only trained and approval surgeon could perform the PIPAC procedure. All four interviewed practitioners agreed that it was initially a good way to implement the procedure safely, but later they felt uncomfortable about the control and validation by the industry. CONCLUSION: Based on the growing number of published papers from a growing number of international centres, the controlled training model is not limiting. However, the different levels of conflict of interest complicate transparency, and we postulated that this development model is limited to the beginning of the procedure diffusion. CLINICALTRIAL. GOV REGISTRATION: NCT04341337.

Thoracic osteotomy for Gorham-Stout disease of the spine: a case report and literature review.

INTRODUCTION: Gorham-Stout syndrome is an aggressive, non-heritable skeletal disease characterized by osteolysis following minor trauma. The primary involvement of the spine is less common (10 %) and has been described in only about 20 cases; there is no consensus about the best way to treat this condition. PURPOSE OF THE STUDY: To report a case of Gorham-Stout syndrome involving the thoracic spine and to review the literature to suggest a post-operative treatment to prevent osteolysis. CASE REPORT: A thirty-year-old female patient was admitted to the unit in March 2013 for a pathologic T4 fracture. X-rays and CT scan revealed the onset of T4 osteolysis and an increase in thoracic kyphosis (the local kyphosis was up to 100°). We performed surgery by posterior approach, combining posterior fixation with screws and rods from T3 to T9, decompression and vertebral osteotomy of 65°. The immediate outcome of surgery was good and the patient returned home after 24 days. At 6 and 12 months of follow-up, the patient was walking normally with no neurological sequelae. CONCLUSION: We report a case of Gorham-Stout syndrome involving the thoracic spine that was successfully treated by interpedicular osteotomy associated with a 6 month follow-up. We suggest that this strategy can provide good results, because after fusion, the disease process remains stable. Because of the lack of cases reported, surgeons must be careful when using multiple treatments, because these treatments have many side effects. LEVEL OF EVIDENCE: Level IV case report.

Reference ranges for serum periostin in a population without asthma or chronic obstructive pulmonary disease.

BACKGROUND: The clinical utility of serum periostin as a type 2 biomarker in asthma is limited by lack of reference range values derived from a population without respiratory disease. OBJECTIVE: To derive age- and sex-related reference intervals for serum periostin from an adult population without asthma or COPD. METHODS: Serum periostin levels were measured in 480 individuals, comprising 60 female and 60 male adults in each of the 18- to 30-year, 31- to 45-year, 46- to 60-year and 61- to 75-year age groups. Key exclusion criteria included a doctor's diagnosis of asthma, chronic bronchitis or COPD, and a history of wheezing or use of respiratory inhalers in the last 12 months. The distribution of periostin and logarithm-transformed periostin levels was derived, and 90% confidence intervals for an individual prediction were calculated. RESULTS: The distribution of serum periostin was right skewed with a mean (SD) periostin of 51.2 (11.9) ng/mL, median (IQR) 50.1 (43.1 to 56.9) ng/mL and range 28.1 to 136.4 ng/mL. There was no association between logarithm periostin and age or sex, although levels were low in current smokers. The 90% confidence limits for periostin were 35.0 and 71.1 ng/mL. CONCLUSIONS AND CLINICAL RELEVANCE: Serum periostin levels in adults without asthma or COPD are similar to those in adults with asthma. Serum periostin measurements do not need to be adjusted to take account of a patient's age or sex, although levels are lower in current smokers. Reference values for serum periostin levels in adults without asthma or COPD are provided.

Change in acetabular version after lumbar pedicle subtraction osteotomy to correct post-operative flat back: EOS® measurements of 38 acetabula.

BACKGROUND: Abnormalities in acetabular orientation can promote the development of hip osteoarthritis, femoro-acetabular impingement, or even acetabular cup malposition. The objective of the present study was to determine whether pedicle substraction osteotomy (PSO) to correct sagittal spinal imbalance affected acetabular orientation. HYPOTHESIS: PSO performed to correct sagittal spinal imbalance affects acetabular orientation by changing the pelvic parameters. MATERIALS AND METHODS: This was a descriptive study in which two observers measured the acetabular parameters on both sides in 19 patients (38 acetabula) before and after PSO for post-operative flat-back syndrome. Mean time from PSO to post-operative measurements was 19months. Measurements were taken twice at a 2-week interval, on standing images obtained using the EOS(®) imaging system and sterEOS(®) software to obtain 3D reconstructions of synchronised 2D images. Acetabular anteversion and inclination were measured relative to the vertical plane. Mean pre-PSO and post-PSO values were compared using the paired t-test, and P values lower than 0.05 were considered significant. To assess inter-observer and intra-observer reproducibility, we computed the intra-class correlation coefficients (ICCs). RESULTS: The measurements showed significant acetabular retroversion after PSO, of 7.6° on the right and 6.5° on the left (P<0.001). Acetabular inclination diminished significantly, by 4.5° on the right and 2.5° on the left (P<0.01). Inclination of the anterior pelvic plane decreased by 8.4° (P<0.01). Pelvic incidence was unchanged, whereas sacral slope increased by 10.5° (P<0.001) and pelvic tilt decreased by 10.9° (P<0.001). The ICC was 0.98 for both inter-observer and intra-observer reproducibility. CONCLUSION: Changing the sagittal spinal alignment modifies both the pelvic and the acetabular parameters. PSO significantly increases sacral slope, thus inducing anterior pelvic tilt with significant acetabular retroversion. The measurements obtained using sterEOS(®) showed good inter-observer and intra-observer reproducibility. To our knowledge, this is the first study of changes in acetabular version after PSO.

Reproducibility and repeatability of a new computerized software for sagittal spinopelvic and scoliosis curvature radiologic measurements: Keops(®).

PURPOSE: The purpose of this study was to evaluate the inter- and intra-observer variability of the computerized radiologic measurements using Keops(®) and to determine the bias between the software and the standard paper measurement. METHODS: Four individuals measured all frontal and sagittal variables on the 30 X-rays randomly selected on two occasions (test and retest conditions). The Bland-Altman plot was used to determine the degree of agreement between the measurement on paper X-ray and the measurement using Keops(®) for all reviewers and for the two measures; the intraclass correlation coefficient (ICC) was calculated for each pair of analyses to assess interobserver reproducibility among the four reviewers for the same patient using either paper X-ray or Keops(®) measurement and finally, concordance correlation coefficient (rc) was calculated to assess intraobserver repeatability among the same reviewer for one patient between the two measure using the same method (paper or Keops(®)). RESULTS: The mean difference calculated between the two methods was minimal at -0, 4° ± 3.41° [-7.1; 6.4] for frontal measurement and 0.1° ± 3.52° [-6.7; 6.8] for sagittal measurement. Keops(®) has a better interobserver reproducibility than paper measurement for determination of the sagittal pelvic parameter (ICC = 0.9960 vs. 0.9931; p = 0.0001). It has a better intraobserver repeatability than paper for determination of Cobbs angle (rc = 0.9872 vs. 0.9808; p < 0.0001) and for pelvic parameter (rc = 0.9981 vs. 0.9953; p < 0.0001). CONCLUSIONS: We conclude that Keops(®) has no bias compared to the traditionally paper measurement, and moreover, the repeatability and the reproducibility of measurements with this method is much better than with similar standard radiologic measures done manually in both frontal and sagittal plane and that the use of this software can be recommended for clinical application. LEVEL OF EVIDENCE: Diagnostic, level III.

Absence of a food effect with a 145 mg nanoparticle fenofibrate tablet formulation.

OBJECTIVES: The present study was conducted to assess the effect of food on the bioavailability of fenofibric acid from a new tablet formulation containing fenofibrate nanoparticles. METHODS: In this 3-way crossover study, 45 subjects received in a random order one 145 mg fenofibrate tablet under high-fat fed (HFF), low-fat fed (LFF) or fasting (reference) conditions. Plasma concentrations of fenofibric acid were determined up to 120 hours post-dose. Comparisons were made between test (HFF and LFF) and reference conditions (fasting). RESULTS: Very close values of pharmacokinetic parameters were obtained following the three diffiferent regimens. The 90% confidence intervals (CI) for the ratio of geometric means of HIFF versus fasting condition were (1.018-1.088) for AUCinfinity, (1.020-1.090) for AUCt and (0.963-1.054) for Cmax with point estimate:s of 1.052, 1.054 and 1.007, respectively. The 90% CI for the geometric means of LFF versus fasting condition were (0.978-1.046) for AUGinfinity, (0.981-1.047) for AUCt and (0.964-1.055) for Cmax with point estimates of 1.012, 1.013 and 1.009, respectively. They all fall within the required limits for bioequivalence (0.80-1.25). A slightly prolonged tmax was observed following HFF conditions (4.3 +/- 1.9 hours, versus 3.6 +/- 1.2 hours and 2.3 +/- 0.7 hours under LFF and fasting conditions, respectively), without any effect on mean Cmax. CONCLUSION: The peak and overall exposures from the new 145 mg fenofibrate tablet were not affected by food. Therefore, this new fenofibrate tablet may be taken without regard to the timing of meals.

Magnetic resonance angiography: from anatomical knowledge modeling to vessel segmentation.

Magnetic resonance angiography (MRA) has become a common way to study cerebral vascular structures. Indeed, it enables to obtain information on flowing blood in a totally non-invasive and non-irradiant fashion. MRA exams are generally performed for three main applications: detection of vascular pathologies, neurosurgery planning, and vascular landmark detection for brain functional analysis. This large field of applications justifies the necessity to provide efficient vessel segmentation tools. Several methods have been proposed during the last fifteen years. However, the obtained results are still not fully satisfying. A solution to improve brain vessel segmentation from MRA data could consist in integrating high-level a priori knowledge in the segmentation process. A preliminary attempt to integrate such knowledge is proposed here. It is composed of two methods devoted to phase contrast MRA (PC MRA) data. The first method is a cerebral vascular atlas creation process, composed of three steps: knowledge extraction, registration, and data fusion. Knowledge extraction is performed using a vessel size determination algorithm based on skeletonization, while a topology preserving non-rigid registration method is used to fuse the information into the atlas. The second method is a segmentation process involving adaptive sets of gray-level hit-or-miss operators. It uses anatomical knowledge modeled by the cerebral vascular atlas to adapt the parameters of these operators (number, size, and orientation) to the searched vascular structures. These two methods have been tested by creating an atlas from a 18 MRA database, and by using it to segment 30 MRA images, comparing the results to those obtained from a region-growing segmentation method.

CRF2 receptor activation prevents colorectal distension induced visceral pain and spinal ERK1/2 phosphorylation in rats.

BACKGROUND AND AIMS: Activation of corticotropin releasing factor 1 (CRF1) receptors is involved in stress related responses and visceral pain, while activation of CRF2 receptors dampens the endocrine and some behavioural stress responses. We hypothesised that CRF2 receptor activation may influence visceral pain induced by colorectal distension (CRD) in conscious rats, and assessed the possible sites and mechanisms of action. METHODS: Male Sprague-Dawley rats were exposed to CRDs (60 mm Hg, 10 minutes twice, with a 10 minute rest interval). Visceromotor responses (VMR) were measured by electromyography or visual observation. Spinal (L6-S1) extracellular signal regulated kinase 1/2 (ERK 1/2) activation following in vivo CRD and CRF2 receptor gene expression in the T13-S1 dorsal root ganglia (DRG) and spinal cord were determined. Inferior splanchnic afferent (ISA) activity to CRD (0.4 ml, 20 seconds) was assessed by electrophysiological recording in an in vitro ISA nerve-inferior mesenteric artery (intra-arterial)-colorectal preparation. RESULTS: In controls, VMR to the second CRD was mean 31 (SEM 4)% higher than that of the first (p<0.05). The selective CRF2 agonist, human urocortin 2 (hUcn 2, at 10 and 20 microg/kg), injected intravenous after the first distension, prevented sensitisation and reduced the second response by 8 (1)% and 30 (5)% (p<0.05) compared with the first response, respectively. RT-PCR detected CRF2 receptor gene expression in the DRG and spinal cord. CRD (60 mm Hg for 10 minutes) induced phosphorylation of ERK 1/2 in neurones of lumbosacral laminae I and IIo and the response was dampened by intravenous hUcn 2. CRD, in vitro, induced robust ISA spike activity that was dose dependently blunted by hUcn 2 (1-3 microg, intra-arterially). The CRF2 receptor antagonist, astressin2-B (200 microg/kg subcutaneously or 20 microg intra-arterially) blocked the hUcn 2 inhibitory effects in vivo and in vitro. CONCLUSIONS: Peripheral injection of hUcn 2 blunts CRD induced visceral pain, colonic afferent, and spinal L6-S1 ERK 1/2 activity through CRF2 receptor activation in rats.

[Sonographic imaging of lymphatic vessels compared to other methods]. / Apport de l'échographie à l'imagerie des vaisseaux lymphatiques par rapport aux autres méthodes.

This paper reviews for the first time the normal and abnormal appearances of lymphatic channels of the skin using ultrasound. After a review of anatomy and histology, the authors present the current imaging modalities available for lymph vessel imaging. The ultrasound examination is presented with a description of the author's technique as well as the technical requirements of the ultrasound unit (12 MHz linear probe with a resolution of 400 microns). They present the ultrasound appearance of normal lymphatic channels and their relationships to the dermis, hypodermis and lymph nodes, and at last the ultrasound appearance of abnormal lymphatic pathways

[Femoral neuropathy after transversal suspubic laparotomies. Etiopathological explanation on the basis of an anatomical study]. / Paralysie du nerf fémoral dans les suites des laparotomies transversales sus-pubiennes: étude anatomique et hypothèses étiopathogéniques.

OBJECTIVES: Based on a case of transient troncular femoral neuropathy after the surgical treatment of a genital prolapse in a 46-year-old woman, a study was designed to better understand the mechanism of this postoperative complication. METHODS: The consequences of different varieties of transversal laparotomies were investigated in human cadavers. RESULTS: On the basis of the data from the anatomical evaluation, the most probable etiopathogenic explanation for the complication we observed is the compression of the femoral nerve, inside the psoas muscle, by the retractor lower edge. CONCLUSION: In the reported case, the outcome was simple with full sensory and motor recovery in the lower limb. The different mechanisms potentially involved in this kind of postoperative femoral neuropathies are reviewed and discussed.

Peripheral corticotropin-releasing factor and stress-stimulated colonic motor activity involve type 1 receptor in rats.

BACKGROUND & AIMS: Corticotropin-releasing factor (CRF) exerts its action through CRF receptors 1 and 2 (CRF-R1 and CRF-R2). CRF has preferential affinity for CRF-R1, whereas urocortin displays high affinity for both. We investigated changes in colonic motor function after intraperitoneal (IP) injection of CRF-related peptides. METHODS: Colonic motility was recorded in vivo in conscious rats equipped with electrodes chronically implanted in the cecum and proximal colon or in vitro in distal colon; fecal output was monitored in naive rats. RESULTS: Rat CRF, rat urocortin, and amphibian sauvagine (10 microg/kg, IP) induced a new pattern of cecocolonic myoelectric activity characterized by clustered spike bursts of long duration; the percentage of occurrence was highest after CRF. The rank order of potency to increase fecal pellet output after IP peptide injection (0.3-10 microg/kg, IP) was CRF > urocortin = sauvagine. The CRF-R1/R2 antagonist astressin (33 microg/kg, IP) and the CRF-R1 antagonist CP-154,526 (20 mg/kg, subcutaneously) inhibited IP CRF-induced changes in cecocolonic myoelectric activity and IP CRF- and water avoidance stress-induced fecal output. In vitro, CRF injected into the inferior mesenteric artery increased distal colonic myoelectric activity compared with saline injection. CONCLUSIONS: These results demonstrate that CRF acts peripherally to stimulate colonic motility and that CRF-R1 is primarily involved in mediating IP CRF/urocortin- and water avoidance stress-induced colonic motor response.

Operative stress response is reduced after laparoscopic compared to open cholecystectomy: the relationship with postoperative pain and ileus.

Our objective was to determine the least invasive surgical procedure; to do this we compared postoperative pain, duration of ileus, and level of neurohormonal stress response after laparoscopic cholecystectomy (LC) and open cholecystectomy (OC). Postoperative recovery of patients was faster after LC than OC but comparison of the neurohormonal stress response after laparoscopic and open surgical procedures revealed conflicting results. Forty-one consecutive patients with noncomplicated gallstones were randomized for LC (N = 25) and OC (N = 16). The stress level was evaluated in patients before surgery by the Hamilton anxiety scale. Postoperative pain was assessed by a visual analogic scale (VAS) pain score and by the amount of analgesic drugs (propacetamol) administered, while the duration of ileus was determined by the delay between surgery and the time to first passage of flatus as well by the colonic transit time (CTT) measured by radiopaque markers. Plasma concentrations of anti-diuretic hormone (ADH), adrenocorticotropic hormone (ACTH), beta-endorphin (BE), neurotensin (NT), and aldosterone (Ald) were measured before and during surgery as well as 2 and 5 hr after the surgery (D0) and on the day following surgery (D1). Urinary cortisol (uCOR) and urinary catecholamine metabolites were assessed before surgery, during D0, and on D1. Patient characteristics, the duration of surgery, and the doses of anesthetic drugs were not different in LC and OC. In LC patients the VAS pain score and the doses of postoperative antalgics were lower (P < 0.05), the time to first passage of flatus was shorter (P < 0.001), and the CTT tended to be shorter (54 +/- 12 hr vs 81 +/- 17) compared to OC patients. Patients who required the highest doses of postoperative antalgics had the longest delay to first passage of flatus (P < 0.01). During surgery, all neurohormonal parameters increased compared to the preoperative period (P < 0.05), and only plasma NT concentrations were lower during LC than OC (P < 0.05). During the postoperative period, ACTH, BE, Aid, catecholamines, and uCOR concentrations were lower in LC than in OC (P < 0.05). Concentrations of hormonal parameters were higher when the duration of surgery increased (P < 0.05). A greater need for propacetamol to relieve pain was associated with a greater increase in BE, ACTH, and urinary catecholamine levels (P < 0.05-P < 0.005). When the time to first passage of flatus was delayed, levels of BE, ACTH, and catecholamines and NT concentrations were increased (P < 0.05-P < 0.005). In conclusion, LC is less invasive because this surgical procedure induces a shorter neurohormonal stress response than OC, even if the peroperative response is not different. Postoperative pain levels and the duration of ileus are associated with BE, ACTH, and catecholamine levels and NT concentrations, suggesting the importance of hormones in postoperative functional recovery.

How do fiber-supplemented formulas affect antroduodenal motility during enteral nutrition? A comparative study between mixed and insoluble fibers.

BACKGROUND: Fiber supplementation during enteral nutrition has been recommended, but the effect of soluble compared with insoluble fiber supplements on antroduodenal motility is unknown. OBJECTIVE: The objective of this study was to compare antroduodenal motor patterns in 8 healthy volunteers during and after gastric infusion of 3 different diets: a fiber-free diet, an insoluble-fiber diet, and a mixed-fiber diet (50% soluble fiber and 50% insoluble fiber). DESIGN: Manometric studies with the 3 different diets (2100 kJ) were performed in random order. Antroduodenal motility was monitored continuously for 6 h by using a pneumohydraulic system to calculate the number, amplitude, and duration of the pressure waves; the area under the curve (AUC); and the percentage of time occupied by motor activity before, during, and after each type of infusion. Variations in antral areas were measured by ultrasonography. RESULTS: The gastric motor response was significantly higher, whatever the diet, in the distal antral recording site than in the 2 more proximal sites. In the proximal but not the distal antrum, the number of waves, the AUC, and the percentage of time occupied by motor activity were higher (P: < 0.04) with the mixed-fiber than with the insoluble-fiber diet. No significant differences in variations of antral area were observed among the 3 diets. In the duodenum, motor variables were not significantly different among the 3 diets. CONCLUSIONS: A gastric infusion induced a greater motor response in the distal than in the proximal antrum. A mixed-fiber diet was associated with significantly greater proximal antral motility than was an insoluble-fiber diet. There was no significant difference among the 3 formulas in duodenal motor variables or in variations in antral area as measured by ultrasound.

[Ophthalmic artery, optic nerve and meninges: reciprocal relations]. / Artère ophtalmique, nerf optique et méninges: relations réciproques.

The origin of the ophthalmic artery exhibits several variants which can be explained by a vascular morphogenesis study. The particular relations of the ophthalmic artery with the optic nerve and the cranial meninges are examined using serial histological sections.