Impact of the COVID-19 lockdown period on adult musculoskeletal injuries and surgical management: a retrospective monocentric study.

The coronavirus disease 2019 (COVID-19) pandemic has led to the worldwide implementation of unprecedented public protection measures. On the 17th of March, the French government announced a lockdown of the population for 8 weeks. This monocentric study assessed the impact of this lockdown on the musculoskeletal injuries treated at the emergency department as well as the surgical indications. We carried out a retrospective study in the Emergency Department and the Surgery Department of Nantes University Hospital from 18 February to 11 May 2020. We collected data pertaining to the demographics, the mechanism, the type, the severity, and inter-hospital transfer for musculoskeletal injuries from our institution. We compared the 4-week pre-lockdown period and the 8-week lockdown period divided into two 4-week periods: early lockdown and late lockdown. There was a 52.1% decrease in musculoskeletal injuries among patients presenting to the Emergency Department between the pre-lockdown and the lockdown period (weekly incidence: 415.3 ± 44.2 vs. 198.5 ± 46.0, respectively, p < .001). The number of patients with surgical indications decreased by 33.4% (weekly incidence: 44.3 ± 3.8 vs. 28.5 ± 10.2, p = .048). The policy for inter-hospital transfers to private entities resulted in 64 transfers (29.4%) during the lockdown period. There was an increase in the incidence of surgical high severity trauma (Injury Severity Score > 16) between the pre-lockdown and the early lockdown period (2 (1.1%) vs. 7 (7.2%), respectively, p = .010) as well as between the pre-lockdown and the late lockdown period (2 (1.1%) vs. 10 (8.3%), respectively, p = .004). We observed a significant increase in the weekly emergency department patient admissions between the early and the late lockdown period (161.5 ± 22.9, 235.5 ± 27.7, respectively, p = .028). A pronounced decrease in the incidence of musculoskeletal injuries was observed secondary to the lockdown measures, with emergency department patient admissions being halved and surgical indications being reduced by a third. The increase in musculoskeletal injuries during the late confinement period and the higher incidence of severe trauma highlights the importance of maintaining a functional trauma center organization with an inter-hospital transfer policy in case of a COVID-19s wave lockdown.

Functional assessment of transplantar nailing for ankle fracture in the elderly: 48 weeks' prospective follow-up of 14 patients.

INTRODUCTION: Retrograde transplantar intramedullary nailing (TIMN) is a recently described option for ankle fracture in elderly patients with multiple comorbidity contraindicating classical internal fixation. The main objective of the present study was to assess mobility after TIMN for ankle fracture in the elderly. The secondary objective was to assess complications. HYPOTHESIS: Retrograde TIMN provides reliable fixation of ankle fracture in the elderly, enabling early resumption of walking. MATERIAL AND METHODS: Fourteen patients, with a mean age of 79.6years (range: 65-99years), with fracture of the ankle or tibial pilon treated by retrograde TIMN, were prospectively included over a 1-year period (2014-2016). Full weight-bearing with walking cast boot was authorized as of day 1. Mobility was assessed on Parker score in consultation at 6, 12, 24 and 48 weeks. RESULTS: Ten patients were followed up. Mean Parker score was 3.6 (range: 1-5) preoperatively, and 2.4 (range: 1-5) and 2.7 (range: 1-5) at 24 and 48 weeks, respectively: i.e., not significantly different from preoperative values (p=0.057 and p=0.054, respectively). There were no decubitus-related complications. Two patients (20%) showed other complications, including 1 deep infection requiring material ablation. Consolidation was systematic, without hindfoot malunion. DISCUSSION: Retrograde TIMN appeared to be a useful option for ankle fracture in elderly patients for whom classical internal fixation was contraindicated. It allowed immediate resumption of weight-bearing and early rehabilitation, with no increased morbidity or mortality. LEVEL OF EVIDENCE: IV.

Pectoralis Major Tear with Retracted Tendon: How to Fill the Gap? Reconstruction with Hamstring Autograft and Fixation with an Interference Screw.

Rupture of the pectoralis major tendon is considered an uncommon injury and a significant number of ruptures are missed or diagnosed late, leading to a chronic tear. We report an open reconstruction technique and its outcomes in a case of chronic and retracted PM tear. At the last follow-up (12 months), the patient was pain-free, with a visual analogic scale at 0 all the time. He was very satisfied concerning the cosmetic and clinical results. The constant score was 93%, the SST value 95%, and the Quick DASH score 4.5. MRI performed one year postoperatively confirmed the continuity between PM tendon and graft, even if the aspect of the distal tendon seemed to be thinner than normal PM tendon. The excellent clinical outcomes at one-year follow-up suggest that PM tear with major tendon retraction can be reliably reconstructed with hamstring autograft, using a bioabsorbable screw to optimize the fixation device. This technique has proven its simplicity and efficiency to fill the gap.

Minimally invasive internal fixation of distal femur fractures.

Fractures of the distal femur remain a daunting challenge. Since 1970, operative treatment has been recommended. Unfortunately, it is fraught with complications, and techniques have been developed to limit incidence of non-union, infection and stiffness. A soft-tissue friendly approach is the key point, with minimally invasive surgery as the ultimate goal: its biological and anatomical advantages have been demonstrated, but clinical studies have been less convincing, being based on historical series. At present, retrograde nailing and minimally invasive percutaneous plate osteosynthesis (ideally by locking plate) are the two main techniques. Unfortunately, reports tend to compare implants rather than operative techniques, hindering solid conclusions. Lastly, the delineation of "distal femur fracture" is quite variable, sometimes situated well above the AO epiphyseal square. Meta-analyses find almost no difference between the two implants in minimally invasive procedures. The main advantage of the plate is its versatility, whereas nailing can be impossible in case of certain hip or knee prostheses, compound articular fracture or medullary canal obstruction by fixation material (nail, stem, screw, etc.). The role of arthroscopy is limited. Only a few case reports describe its use in reduction of epiphyseal fracture. In the last analysis, the surgeon's experience is more relevant to outcome than any particular implant.

Proximal ulnar fractures in adults: a review of 163 cases.

The aim of this study was to report the epidemiological characteristics and the experience of 5 departments of trauma, in France, in the management of fractures of the proximal ulna. 163 patients with fractures of the proximal ulna with a mean age of 49.9 years (range 16-97) were managed. The most common mode of injury was a motor vehicle collision (48%). 18% sustained associated injuries to the ipsilateral limb. Open fractures were present in 42 patients (25%). A total of 109 patients had a fracture of the olecranon, with the Mayo 2A and B types most frequently seen (66%). The patients were invited for clinical examination at a mean duration of 16 months, retrospectively. Validated patient-oriented assessment scores involving the Mayo Elbow Performance Index (MEPI) and the Broberg and Morrey score were evaluated. All patients had follow-up radiographs. The mean arc of elbow motion was 130° (70-150°). The mean MEPI was 91 (20-100) with good results in 23% and excellent results in 52% of the patients. The mean Broberg and Morrey score was 90 after isolated olecranon fracture, and decreased with the complexity of the lesion. 117 fractures (72%) healed with ulnohumeral congruity. 9 fracture non-unions occurred (6%). Although the fracture of the proximal ulna can be described in several classifications, none of them accommodate it satisfactorily, because of the complexity of the lesion. The coronoid process is the keystone for the stability of the elbow. It forms the anterior buttress with the radial head. Tension band wire fixation is by far the commonest technique of internal fixation used for the treatment of non-comminuted olecranon fractures. Dorsal plate fixation is a useful option by providing improved fixation of complex comminuted fractures and fracture-dislocations. The radiocapitellar joint has to be restored appropriately, preserving the radial head when possible and replacing it with a prosthesis otherwise. The lateral collateral ligament complex is commonly disrupted and usually can be reattached to its origin from the lateral epicondyle. In addition, a brief period of hinged external fixation should be considered.

Traumatic Floating Knee: A Review of a Multi-Centric Series of 172 Cases in Adult.

The traumatic floating knee in adults (FK) is a combined injury of the lower limb defined by ipsilateral fractures of the tibia and femur. The first publications emphasized the severity of injuries, the bad results after conservative treatment, the most severe functional outcome in case of articular fracture and the frequency of associated cruciate ligament injuries. The surgical management of FK has been highly modified according the improvement of the fracture fixation devices and the operative techniques. This retrospective multicentric observational study included 172 adults with a FK injury admitted in emergency in 5 different level I or II trauma centers. All the patients data were collected on an anonymized database. Results were evaluated by the overall clinical Karlström's score at latest follow-up. Fracture union was assessed on X-rays when at least 3 out of 4 cortices were in continuity in two different radiological planes. A statistical analysis was performed by a logistic regression method. Despite some limitations, this study confirms the general and local severity of this high-energy trauma, mainly occurring in young people around the third decade. A special effort should lead to a better initial diagnosis of associated ligamentous injury: a tear of PCL can be suspected on a lateral-ray view and a testing of the knee should be systematically performed after fixation of the fracture under anesthesia. Secondary MRI assessment is sometimes difficult to interpret because of hardware artifacts. The timing of fracture fixation is discussed on a case by case basis. However, a first femoral fixation is recommended except in cases of tibia fracture with major soft tissue lesion or leg ischemia requiring the tibia fixation first. Also a tibia stabilized facilitates the reduction and fixation of a complex distal femur fracture. The dual nailing remains so far for us the best treatment in Fraser I FK. Further prospective studies are needed to validate treatment algorithms, best fixation techniques in order to decrease the rate of complication and improve the functional outcome of floating knee injuries.

Unicondylar fractures of the distal femur.

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.

External fixation of distal femoral fractures in adults' multicentre retrospective study of 43 patients.

BACKGROUND: A multicenter cohort of 43 adults with distal femoral fractures (DFFs) managed with external fixation was evaluated to determine the potential of this treatment. PATIENTS AND METHODS: The patients were young adults (mean age: 39.6 years) with high-energy trauma; 12 had polytrauma and 41 multiple fractures. Most patients (38/43) had compound DFFs. Fracture types were A in 3 patients, B in 3 patients, and C in 37 patients. A tibio-femoral construct was required in 11 patients and a femoro-femoral construct in 32 patients. RESULTS: The normal femoral axis was restored within 5° in the coronal plane in 34 (79%) patients and in the sagittal plane in 22 (51%) patients. Axis restoration within 5° in both planes was achieved in 19 (44.7%) patients. After femoro-femoral external fixation, mean malalignment was 4.2° in the coronal plane and 8.6° in the sagittal plane; corresponding values after tibio-femoral external fixation were 1.3° and 8.6°. In 23 patients (of whom 1 was lost to follow-up), external fixation was intended as the only and definitive treatment; among them, 1 required amputation after a failed revascularization procedure, 10 achieved fracture healing within a mean of 21.2 weeks, 6 required conversion to another technique, and 5 underwent non-conservative procedures (total knee arthroplasty in 3 and arthrodesis in 2). In the remaining 20 patients, conversion to internal fixation was intended initially and performed within a mean of 4.7 weeks; 1 of these patients required amputation for ischemia, 3 did not achieve fracture healing, 12 achieved primary fracture healing, and 4 achieved fracture healing after repeated grafting (n=3) or osteotomy (n=1). At last follow-up (at least 1 year), the mean International Knee Society (IKS) Function Score was 67.3 and an IKS Knee Score of 68.5. Range of active flexion was 85.75° overall, 62.3° in the group with intended definitive external fixation and 101° in the group with intended conversion to internal fixation. Healing without complications was achieved in 10 (43%) in the former group and 12 (60%) in the latter group. CONCLUSION: Our data support provisional external fixation followed by early conversion to internal fixation in patients with extensively compounded DFFs; patients with multiple fractures requiring several surgical procedures; and polytrauma patients awaiting hemodynamic, respiratory, or neurological stabilization. LEVEL OF EVIDENCE: IV, retrospective study.

Locked plating for internal fixation of the adult distal femur: influence of the type of construct and hardware on the clinical and radiological outcomes.

INTRODUCTION: Distal femoral fractures are rare and serious. Along with traditional internal fixation, new, dedicated hardware have appeared (distal nails, locked plating). We report the results of a multicenter prospective study of these fractures treated with locked plating. HYPOTHESIS: The short-term results are satisfactory and related to the type of construct and the hardware used, with better results for elastic assemblies and titanium implants. MATERIALS AND METHODS: From June 2011 to May 2012, 92 patients, mean age 64 years, were included in 12 centres. The fractures were classified as follows: 44 type A, 7 type B, and 41 type C according to the AO classification. Thirteen fractures were open. The plates were uniaxial. The assemblies were elastic in 52 cases, rigid in 26, and unconventional in 14. RESULTS: Seventy-six patients underwent a radiological follow-up at 6 months and 66 patients had a clinical result evaluated at 1 year. The mean range of motion was 100° and the mean IKS score was 122. The bone union rate was 87% within 12 weeks. Seven valgus, two varus, ten flexion deformities, and three recurvatum greater than 5° were observed (19.5%). Revisions involved two cases with loss of fixation, five cases of infection, and one case of arthrofibrosis (requiring arthroscopic arthrolysis). Secondary bone grafting was carried out in seven cases (four successfully). No influence of the type of assembly or the hardware used was demonstrated. DISCUSSION: The results remain modest, underscoring the severity of these fractures. Neither the type of construct nor the hardware used influenced the radiological and clinical outcomes. The hypothesis was not confirmed. LEVEL OF EVIDENCE: Level IV prospective, non-comparative study.

Epidemiology of distal femur fractures in France in 2011-12.

INTRODUCTION: Epidemiological study of femoral fractures has been dominated by proximal fractures. Distal fracture requires equal attention for correct management. PATIENTS AND METHODS: A prospective study in 12 French hospital centres between June 1st, 2011 and May 31st, 2012 recruited cases of non-pathologic distal femoral fracture in patients over 15 years of age without ipsilateral knee prosthesis. RESULTS: There were 183 fractures in 177 patients. Mean age was 63.5 years. Female patients (60.5%) were significantly older than males (mean age, respectively 73 versus 48.4 years). Walking was unrestricted in only 83 patients (46.89%). On the AO/OTA (Orthopaedic Trauma Association) classification, there were 86 type A fractures (47%), 29 type B (15.8%) and 68 type C (37.2%). Fractures were open in 32 cases (17.5%), most frequently in male, young patients and type C fracture. Causal trauma was low-energy (fall from own height) in 108 cases, most frequently in female patients and type A fracture. Forty-five patients were proximal femoral implant bearers. CONCLUSION: Distal femoral fracture shows highly variable epidemiology. AO/OTA type A fracture mainly involves elderly, relatively dependent female subjects. Outcome study requires radiographic data and assessment of functional capacity. LEVEL OF EVIDENCE IV: Prospective cohort study.

Blade-plate fixation for distal femoral fractures: a case-control study.

BACKGROUND: The blade-plate is the earliest of the contemporary internal fixation devices introduced for distal femoral fractures. The recent development of dedicated, fixation devices has considerably limited its use. The objective of this study was to evaluate outcomes after blade-plate fixation and after fixation using other devices. HYPOTHESIS: Outcomes after blade-plate fixation are similar to those after condylar screw-plate, distal femoral nail, or locking condylar plate fixation. MATERIAL AND METHODS: We reviewed outcomes after 62 patients managed with blade-plate fixation and included in a multicentre retrospective study (n=57) or a multicentre prospective study (n=5) and we compared them to outcomes after fixation using condylar screw-plates (n=82), distal femoral nail (n=219), or locking condylar plates (n=301). The four groups were comparable for age, gender distribution, occupational status, prevalence of skin wounds, patient-related factors, type of accident, and type of fracture. The evaluation relied on the clinical International Knee Society (IKS) score and on radiographs. RESULTS: No significant differences existed across the four groups for operative time, blood transfusion use, complications, need for bone grafting, non-union rate, or IKS score values. The early surgical revision rate for removal of the fixation material was 4% with the blade-plate and 16% with the other three fixation devices (P=0.02). Post-operative fracture deformity was similar in the four groups with, however, a higher proportion of residual malalignment in the screw-fixation group. The final anatomic axis was 3.3±1.4° with the blade-plate versus 2.3±3.7° with the other three fixation devices. The blade-plate group had few patients with axial malalignment, and the degree of malalignment was limited to 3° of varus and 10° of valgus at the most, compared to 10° and 18° respectively, with the other three fixation devices. CONCLUSION: Despite the now extremely limited use and teaching of blade-plate fixation, as well as the undeniable technical challenges raised by the implantation of this device, the blade-plate is a simple, strong, and inexpensive fixation method. It remains reliable for the fixation of distal femoral fractures. The disfavour into which the blade-plate is currently falling is not warranted. LEVEL OF EVIDENCE: III, case-control study.

Isolated anterior unilateral sacroiliac dislocation without pubic arch disjunction.

Sacroiliac joint dislocations frequently occur in a context of high-energy polytrauma. When there is disruption of the pelvic ring, sacroiliac joint displacements are more often posterior and combine two lesions: either lesions of the pubic arch as well as the posterior arch or bilateral lesions. The case we report here lacks these two characteristics. This is an isolated unilateral sacroiliac dislocation with no opening lesion of the pubic symphysis or fracture of ilio- or ischiopubic rami and with anterosuperior displacement. After emergency reduction of the dislocation, the secondary fixation was not performed, due to initial hemodynamic instability compounded by deteriorating central nervous system condition.

Primary total knee arthroplasty in the management of epiphyseal fracture around the knee.

INTRODUCTION: Over the past few years the use of arthroplasty was broadened to treating complex epiphyseal fractures at the shoulder and elbow joints. Similar trends to treat this type of fractures at the knee are less documented. Based on a multicenter retrospective series study, the aims of this work is to evaluate the short term clinical results of total knee prostheses in the management of comminuted epiphyseal fractures around the knee, to identify the technical issues and fine tune the indications. MATERIAL AND METHODS: Following the initiative of the French Hip and Knee Society (SFHG) and the Traumatology Study Group (GETRAUM), 26 charts from eight different centers in France were included in this multicenter retrospective series. Inclusion criteria were: primary total knee arthroplasty (TKA) in the management of complex articular fractures involving the proximal end of the tibia or distal end of the femur. Surgical features were identified and complications were analyzed. The assessment protocol at last follow-up was standardized and included patient demographic data, analysis of the Parker and IKS scores. RESULTS: During the immediate postoperative period, six patients (23%) reported a general complication and four patients (15%) a local arthroplasty-related complication. At last follow-up (mean 16.2 months), the overall final Parker score was 6.3 (a mean decrease of 1.7) and the mean IKS knee score was 82 points for a mean function score of 54 points. DISCUSSION: Primary TKA is a suitable management option for complex fractures in autonomous elderly patients suffering from knee osteoarthritis. The key technical details of this procedure should be respected and meticulously planned to achieve optimal results and limit the risk of complications. This risk in these acute complex fractures remains higher than after conventional TKA but comparable to that observed after TKA for post-traumatic arthritis. LEVEL OF EVIDENCE: IV; retrospective cohort study.

The concept of locking plates.

After a short historical review of locking bone plates since their inception more than a century ago to the success of the concept less than 15 years ago with today's plates, the authors present the main locking mechanisms in use. In the two broad categories - plates with fixed angulation and those with variable angulation - the screw head is locked in the plate with a locknut by screwing in a threaded chamber on the plate or by screwing through an adapted ring. The authors then provide a concrete explanation, based on simple mechanical models, of the fundamental differences between conventional bone plates and locking plates and why a locking screw system presents greater resistance at disassembly, detailing the role played by the position and number of screws. The advantages of epiphyseal fixation are then discussed, including in cases of mediocre-quality bone. For teaching purposes, the authors also present assembly with an apple fixed with five locking screws withstanding a 47-kg axial load with no resulting disassembly. The principles of plate placement are detailed for both the epiphysis and diaphysis, including the number and position of screws and respect of the soft tissues, with the greatest success assured by the minimally invasive and even percutaneous techniques. The authors then present the advantages of locking plates in fixation of periprosthetic fractures where conventional osteosynthesis often encounters limited success. Based on simplified theoretical cases, the economic impact in France of this type of implant is discussed, showing that on average it accounts for less than 10% of the overall cost of this pathology to society. Finally, the possible problems of material ablation are discussed as well as the means to remediate these problems.

[The floating knee: a retrospective analysis of 172 cases]. / Le genou flottant: étude rétrospective de 172 cas.

A retrospective multicentric observational study of 172 floating knee injuries is reviewed. According Fraser's classification 71.5% of the cases are type I and the repartition of the type II in the 3 subgroups is as follow: II A 8.2%, II B 11.6%, et II C 8.7%. At least one of the fractures was open in 69.2% of the patients. The average Injury Severity Score (ISS) was 19.5. The polytraumatized patients (ISS over 18) represented 37.7% of the cases. The surgical procedure started within the 6 first hours in 62% of the injured people. The Intramedullary nailing (IM) was the preferred method at the femur site (73%, 126 cases), at the tibia IM was performed in 54.4% of cases and external fixation was used in one every four patients. The mean operating time was 167 minutes (range: 40'-300') and the total time for the whole procedure was 216 minutes (range: 80'-410'). The mean follow up is 34.2 months. According the functional score of Karlström and Olerud, 23 patients were rated as excellent, 38 as good, 35 as fair and 20 as bad. The contributing factors influencing bad functional outcome are the age, a type II lesion, a femoral fracture located at the distal third, and an open fracture. The IM using a single knee incision does not show in this series better results but the shortening of the operating time was highly significant.

Zyxin is up-regulated during megakaryocytic differentiation of human UT-7/c-mpl cells.

To characterize genes involved in megakaryocytic commitment, we compared expression profiles of bipotent cells (UT-7/c-mpl) with those of the same cells induced to differentiate towards megakaryopoiesis in the presence of TPO. Using cDNA arrays, we showed that 12 out of 2260 genes changed their expression level after 6h of TPO stimulation. One of these genes encodes for zyxin, a cytoskeleton protein component. Zyxin is up-regulated at the mRNA and protein levels in UT-7/c-mpl cells in response to TPO confirming the reliability of the cDNA array technology. Similarly, when CD34 positive cells were induced to differentiate into megakaryocytes, zyxin mRNA was accumulated. Furthermore, when megakaryocytes were allowed to spread on fibrinogen, formation of stress fibers and lamellipodia was induced and zyxin was localized at the picks of actin stress fibers. These results suggest an important role for zyxin during megakaryocytic differentiation and more precisely in the regulation of the integrin mediated adhesion process in megakaryocytes.

[Factors affecting quality of care for elderly subjects undergoing surgery for hip fracture: review of the literature]. / Facteurs de qualité de la prise en charge des sujets âgés opérés d'une fracture de l'extrémité supérieure du fémur: revue de la littérature.

Hip fractures are one of the leading causes for admission of elderly subjects to healthcare facilities. Because of population aging, the incidence of hip fractures has increased considerably over the last years and will continue to increase in industrialized countries. Hip fracture in an elderly subject may be life threatening and has a significant functional and social impact not only because of the fracture itself, but also because of the risk of complications related to the patient's health status and the long hospital stay. The purpose of this work was to identify in the published literature professional practices, excepting the surgical procedure, associated with better early and long-term outcome in elderly patients with hip fracture. Questions raised concerning the patient's hospital stay include factors related to the preoperative phase (time to surgery, usefulness of traction), the operation itself (antibiotic prophylaxis, anesthesia technique), and the postoperative phase (prevention of venous thrombosis, malnutrition, episodes of confusion, duration of indwelling bladder catheter, correction of anemia, geriatric care during the stay in the orthopedic ward, early and intense rehabilitation, prevention of recurrence). Among these factors, several appear to be associated with better outcome, including long-term outcome--surgery as early as possible in light of the patient's general status, antibiotic prophylaxis in accordance with standard recommendations (SFAR), prevention of venous thrombosis with low-molecular-weight heparin initiated at admission and associated with elastic contention. Oral nutritional support is probably beneficial and should be proposed for all patients. Particular attention must be given to prevention of confusion in order to reduce the rate of institutionalization. The rythm of rehabilitation exercises should be at least five sessions per week. Finally, there are several methods, which are effective in preventing recurrence, taking into account osteoporosis, risk of falls. Preventive measures should be instituted for all patients undergoing surgery for hip fracture.

Automatic quantitation of hybridization signals on cDNA arrays.

Large-scale hybridization of simple or complex cDNA probes to cDNA clones arrayed on high-density filters is a method frequently used to determine systematically the expression profiles of thousands of genes. Hybridization signal intensities, which reflect the level of transcription of the corresponding genes, are captured on phosphor screens with an imaging system. We describe a high-throughput system, Xdots-Reader, that performs automatic detection and quantitation of each signal on hundreds of images. Reproducibility of spot detection and quantitation within filters and between filters has been assessed in analysis of more than 850000 hybridization signals on 436 filters. The automatic analysis success was greater than 97%, with 424 of the 436 tested filters fully analyzed without any human intervention. XdotsReader is available from the Software Library at www.BioTechniques.com or at http://www. ami. univ-evry. fr/approximately tahi/XDotsReader. It runs on SUN workstations under UNIX (SunOS or Solaris) and on PC under LINUX. No particular hardware is required, and the software is compatible with any other software. It supports the main standard image formats.

Identification of altered gene expression in skeletal muscles from Duchenne muscular dystrophy patients.

Mutations in the dystrophin gene lead to dystrophin deficiency, which is the cause of Duchenne muscular dystrophy (DMD). This important discovery more than 10 years ago opened a new field for very productive investigations. However, the exact functions of dystrophin are still not fully understood and the complex process leading to subsequent muscle fiber necrosis has not been clearly described; hence there has not yet been any marked improvement in patient treatment. To decipher the molecular mechanisms induced by a lack of dystrophin, we started identifying genes whose expression is altered in DMD skeletal muscles. The approach was based on differential screening of a human muscle cDNA array. Nine genes were found to be up- or downregulated. Our results indicate expression alterations in mitochondrial genes, titin, a muscle transcription factor and three novel genes. First characterizations of these novel genes indicated that two of them have striated muscle tissue specificity.