Variations of the obturator nerve and implications in obturator nerve entrapment treatment: an anatomical study.

INTRODUCTION: Obturator nerve entrapment or idiopathic obturator neuralgia is an unfamiliar pathology for many physicians which can lead to diagnostic errancy. This study aims to identify the potential compression areas of the obturator nerve to improve therapeutic management. MATERIAL AND METHODS: 18 anatomical dissections of lower limbs from 9 anatomical cadavers were performed. Endopelvic and exopelvic surgical approaches were utilized to study the anatomical variations of the nerve and to identify areas of entrapment. RESULTS: On 7 limbs, the posterior branch of the obturator nerve passed through the external obturator muscle. A fascia between the adductor brevis and longus muscles was present in 9 of the 18 limbs. The anterior branch of the obturator nerve was highly adherent to the fascia in 6 cases. In 3 limbs, the medial femoral circumflex artery was in close connection with the posterior branch of the nerve. CONCLUSION: Idiopathic obturator neuropathy remains a difficult diagnosis. Our cadaveric study did not allow us to formally identify one or more potential anatomical entrapment zones. However, it allowed the identification of zones at risk. A clinical study with staged analgesic blocks would be necessary to identify an anatomical area of compression and would allow targeted surgical neurolysis.

Simultaneous bilateral total knee arthroplasty. A multicenter feasibility study.

INTRODUCTION: The value and risk of simultaneous total knee arthroplasty (TKA) in patients with bilateral knee arthritis is a subject of debate. HYPOTHESES: The risk of complications following simultaneous bilateral TKA will be increased compared to the rates published in the literature for unilateral TKA, and the clinical and functional outcomes will be poorer in this particular group. MATERIALS AND METHODS: One hundred and twenty-three patients who underwent simultaneous bilateral TKA between 2005 and 2011 in five specialized, high volume centers were evaluated. The files were analyzed retrospectively after a mean 33 months of follow-up. RESULTS: The mean hospital stay was 11 days. Mean blood loss was 4.1g/dL. A postoperative transfusion was performed in 68 patients (55%), with a mean 3.1 units of blood. The mean global IKS score increased from 90 to 150 points. Eighty patients would agree to undergo simultaneous bilateral TKA again (65%), and 70 would recommend this procedure to others (57%). DISCUSSION: The hypothesis was not confirmed: the risk of complications was not increased compared to the generally accepted risk of a unilateral procedure. The risk of complications in this study was very similar to that published in the literature for the same therapeutic strategy. Therefore, there is no solid medical evidence to prevent recommending this strategy. The results of the participating centers suggest that this therapeutic approach should be continued in selected indications. LEVEL OF EVIDENCE: IV, retrospective study.

One-stage bilateral total hip arthroplasty: functional outcomes and complications in 112 patients.

BACKGROUND: Advantages of one-stage bilateral total hip arthroplasty (THA) include a single hospital stay, a shorter rehabilitation time, and decreased management costs per patient. However, concern about a possible increase in the perioperative complication rate has limited the use of this strategy. Here, our objectives were to evaluate morbidity and mortality, as well as functional outcomes, in patients managed with one-stage bilateral THA. HYPOTHESIS: The complication rate after one-stage bilateral THA is not significantly different from that after unilateral THA. MATERIALS AND METHODS: Four French surgical centres participated in a retrospective observational study of patients managed with one-stage bilateral THA. The 112 included patients (55 women) had a mean age of 59 years (range, 22-84) and a mean follow-up of 30 months (6-103). RESULTS: Mean hospital stay length was 10.8 days (6-27), mean operative time was 162 minutes (95-270), and mean haemoglobin levels were 14.3g/dL preoperatively and 10.1g/dL postoperatively. No perioperative deaths were recorded. Deep vein thrombosis occurred in eight (7.1%) patients and pulmonary embolism in six (5.4%). The Merle d'Aubigné score improved from 9.25 ± 2.9 (3-16) preoperatively to 17.5 ± 1 (14-18) at last follow-up. All but three patients (109/112, 97%) said they would choose the same operation again and 102/112 (91%) said they would recommend it to a family member. DISCUSSION: The results of this multicentre retrospective study indicate that one-stage bilateral THA is a valid alternative to two-stage bilateral THA in ASA 1 and 2 patients with a preoperative haemoglobin level of about 14 g/L. The major complication rate was 7.1%, which was slightly higher than after unilateral THA, and the main complications were deep vein thrombosis and pulmonary embolism.

[Air permeable diaphyseal obturators: efficacity of femoral cementing and prevention of associated cardiovascular disorders]. / Obturateur diaphysaire perméable aux gaz: étude d'efficacité sur la cimentation fémorale et la prévention des désordres cardio-respiratoires associés.

PURPOSE OF THE STUDY: Insertion of cement plugs into the femoral shaft has become an essential part of total hip arthroplasty procedures. The goal is to achieve secure cementing of the femoral component, but the pressure induced can cause serious problems. The purpose of this study was to determine the effect of a flexible bioabsorbable cement restrictor with decompression valves on cementing efficacy and to determine the effect of inserting the restrictor then the cement plug into the femoral shaft on respiratory functions. MATERIAL AND METHODS: The restrictor was implanted in 108 patients undergoing first-intention total hip arthroplasty. The canal was prepared and calibrated before inserting the restrictor at a depth estimated at preoperative planning to be 10 to 20 mm below the tip of the femoral stem. The efficacy of the restrictor was assessed using radiographic criteria for the quality of the cement sheath and its position relative to the femoral stem. Oxygen saturation of arterial blood and end-expiration PCO2 were measured at first incision, at insertion of the restrictor, at insertion of the cement plug, and at insertion of the femoral stem. RESULTS: The relative position of the restrictor was measured on postoperative x-rays at less than 20 mm in 75% of the patients, at 20-40 mm in 13% and at more than 40 mm in 12%. No cement leakage through the restrictor was identified on postoperative x-rays. The quality of the cement sheath was satisfactory in 71% of the patients (77 procedures), fair in 20% (22 procedures) and poor in 8% (9 procedures). For a first group of patients operated on under spinal anesthesia and optional oxygen delivered with a face mask, there was no significant difference in arterial blood oxygen saturation before the procedure and during the four explored operative times. Conversely, in a second group of patients who had general anesthesia without oxygen enrichment of the initial oxygen-nitrogen protoxide gas mixture, arterial blood oxygen saturation during the four operative times was statistically different from the preoperative value. The same observation was made for end-expiratory PCO2. DISCUSSION: The retrictor's decompression valves did not allow cement leakage beyond the restrictor. The risk of restrictor migration after insertion and after the increased pressure due to cement plug insertion was not increased and was found to be less than rates reported in the literature. In the patients who had general anesthesia, blood gases showed a minimal, but significant, decrease during the operative times susceptible to induce increased intramedullary pressure. In patients who had a non-cemented acetabular insert, use of the pressure-valve cement restrictor appeared to stabilize these parameters.

[Subdural hematoma and anticoagulant therapy]. / Hématome sous-dural et thérapeutique anticoagulante

The authors report a series of 22 cases of subdural hematomas in patients submitted to anticoagulant therapy. A review of the literature finds 150 cases. Subdural hematomas occurs in about one third of the patients presenting hemorrhage of central nervous system related to anticoagulant therapy. Among subdural hematomas of any cause, the possible role of a previous anticoagulant therapy is stressed in 4,8 to 14% of cases. In most cases, long term anticoagulants were indicated for arterial or heart (ischemic) lesions (16/22 cases). In 6 cases, anticoagulants were indicated for prevention or treatment of pulmonary embolies. In 18 cases, anticoagulant drug is from the group of dicoumarol or phenylindanedione. In 3 cases, the only anticoagulant given to patient was heparin. Pathogenic study suggests that hypocoagulability might not always be the only factor of bleeding: high blood pressure, other drugs and head trauma (10 cases) are often associated. Clinical features, in our series, are similar to those encountered in cases of subdural hematoma of any cause. According to the existence of a cranial injury and to the chronology of anticoagulant therapy, the authors divide their 22 patients into 3 groups. The use of protamin sulfate or human plasma fraction PPSB provides in few minutes a normal coagulability. Neurosurgical treatment in all our cases evacuated in 11 patients a chronic subdural hematoma, in 2 cases an acute, and in 9 cases a subacute hematoma. Results were fair in 19 patients with no sequelae. 3 patients died during the immediate post-operative period. The authors conclude by stressing several preventive measures.