Hemi-Masquelet technique and nailing in a circumferential bone defect of 7 cm after open femoral shaft fracture. A case report.

The treatment of Gustilo-Anderson type III open femoral fracture with large segmental bone defect remains a challenge for orthopedic trauma surgeons. The aims of management are first to prevent the risk of infection and then to reconstruct the bone loss with correct alignment and length. The induced membrane technique (or Masquelet technique) was initially described for tibia nonunion but became over the years an established procedure to treat any kind of large bone defect. The case of a 22-year old male who sustained an open femoral shaft fracture with a circumferential 7-cm bone defect after a car accident is presented. Given the critical size of the bone loss, we chose to manage this patient using a modified-Masquelet technique, in which we stabilized the fracture by an intramedullary femoral nail and filled only the lateral side of the defect with a cement spacer. He went on to have a full and successful union of his fracture 16-weeks after the second stage surgery. The final functional outcomes were excellent allowing the patient to resume all activities without restriction.

Articular fracture of the distal humerus classified Dubberley 2b: Case report of two patients and review of the literature.

Articular fractures of the distal humerus are rare, and even rarer are fractures involving the trochlea and capitellum in a single fragment, with no associated comminution. These fractures are classified as 2a according to the Dubberley classification and are rarely described in the literature. Two cases of Dubberley 2a fractures were treated at our hospital. The first case, involving a 68-year-old patient, was treated with a medial and a lateral approach, combined with posteroanterior fixation using 3 Herbert screws. In the 2nd case, a 16-year-old male was treated with a single lateral approach, permitting fixation with two Herbert screws. One of the two screws is inserted into the bone at the edge of the cartilage, with an anteroposterior trajectory that leaves the cartilage intact. We opted mainly for posteroanterior screw fixation in subchondral bone, which is less damaging to articular cartilage and soft tissues and has already demonstrated its reliability. No associated lesions were found, and no complications were encountered. Results were excellent, with Mayo Elbow Performance Index (MEPI) scores of 95 and 100 respectively. Herbert screw fixation therefore appears to be an option of choice for these fractures, although comparative studies are needed to evaluate the different treatments available.

Advanced finger infection: more frequent than expected and mostly iatrogenic.

Some patients present at an advanced stage of their fingertip infection with an extension of the infection in anatomical spaces or into fragile structures. One hundred and twenty-five patients have been operated on for a finger infection. Forty-one patients (33%) have been treated at the "complication" stage, while 84 cases (67%) were considered "non-complicated". The delay between initial injury and the surgical treatment was 12 days in the "non-complicated" group versus 30 in the "complication" group (p < 0.001). Osteitis (39% of the complications), and flexor sheath infection (37%) were the most frequent complications. Prescribing preoperative antibiotics increases the risk of being in the "complicated" group at p = 0.09. One hundred and thirteen patients (90.4%) were cured of their infection after a single operation. Neither the cause of infection, nor the type of germ or associated diabetes increased the risk of complication in our series. A better education of the first interveners (general practitioner or emergency doctor) in hand infection care could reduce the rate of complication allowing a faster access to hand surgeons.

Surgical anatomy of the preauricular anteroparotid approach for mandibular condyle surgery.

PURPOSE: The different surgical approaches used to treat mandibular condyle fractures are carried out in the periparotid skin area and can lead to facial nerve injury. We conducted a preauricular and anteroparotid surgical approach. Our main aim was to show the anatomical relationship between this approach site and the facial nerve branches, and to define cutaneous landmarks to locate the extraparotid facial nerve branches. METHOD: A 2-step dissection of 13 fresh human cadaver semi-heads was performed: a preauricular approach followed by a superficial parotidectomy to visualize the facial nerve. Its course and ramifications were studied and compared to cutaneous landmarks. The proximity of the facial nerve branches with the surgical approach site was observed. RESULTS: The approach allowed systematically visualising the zygomatic and/or buccal branches. No facial nerve branches were sectioned. In three cases (23 %), a nerve branch was visualized during the approach. The buccal and zygomatic branches were ramified in 77 % of cases. CONCLUSIONS: During our preauricular anteroparotid approach, the buccal and zygomatic branches were visualized but none was sectioned. Most often the approach was carried out between these two branches (46 % of cases). Cutaneous landmarks used were reliable to define a safe and nerve-free area for dissection. The buccal and zygomatic branches are very interesting because their high number of ramifications and anastomoses could serve as nerve relays in case of surgical lesion.

Distraction-free ankle arthroscopy for anterolateral impingement.

The origin of chronic pain after external ankle sprain is better known with arthroscopy's contribution. Chronic hypertrophic synovitis of the anterolateral ankle region is seemingly the cause, resulting in "anterolateral ankle impingement." But is partial synovectomy with fibrosis resection under arthroscopy always possible without any distraction? Are results affected? This retrospective study concerned only patients with soft tissue ankle impingement. All cases with bone and joint diseases were excluded. The final sample of 24 patients had a mean age of 35 years (21-54 years) and presented anterolateral mechanical pain associated with oedema following external ankle sprain. Medical and rehabilitative treatment was undertaken for more than 6 months before arthroscopy. Average time between trauma and arthroscopy was 21 months (5-60 months). Clinical examination revealed no ankle instability or laxity. Debridement with joint lavage was systematically performed under arthroscopy without any distraction. Average patient follow-up was 22 months (12-92 months). All patients had a good Kitaoka score, with 22 patients registering excellent results. There were no septic complications or algodystrophy. Two transient hypoesthesias were observed in the dorsal surface and lateral border of the foot with full postoperative recovery at 6 months. Distraction was never used and simple dorsiflexion was sufficient to perform arthroscopic debridement. In this study, anterolateral ankle impingement diagnosis was primarily clinical. Arthroscopic treatment yielded significant benefits on pain, oedema and resumption of sport activities. Arthroscopic treatment of anterolateral ankle impingements is thus possible with simple dorsiflexion and no distraction, resulting in a possible decrease in complication rates. Level of evidence Retrospective cohort study, Level IV.

Negative pressure wound therapy and external fixation device: a simple way to seal the dressing.

Negative pressure therapy is widely applied to treat lower limb trauma. However, sealing a negative pressure dressing in the presence of an external fixation device may be difficult and time consuming. Therefore, screws, pins, wires, etc, may preclude the vacuum, preventing the plastic drape to perfectly adhere to the foam. To maintain the vacuum, we tried to prevent air leaking around the screws putting bone wax at the junction between the pins and the plastic drape. This solution, in our hands, avoids air leakage and helps maintain vacuum in a fast and inexpensive way.

Compartment syndrome of the thigh after blunt trauma: a complication not to be ignored.

We report a case of anterior thigh compartment syndrome, which occurred after man's thigh was bruised after flipping repeatedly over his bike and being hit by the frame of the bike nearly at around 6 pm. The next day at 1:30 am, he was admitted to the hospital. The initial presentation was a hematoma, and the patient was kept in bed with local cooling. The compartment syndrome of the thigh (CST) diagnosis was made around 6:00 pm when the level of pain was interpreted as disproportionate to the treated lesion; anterior compartment pressure measure was 84 mmHg. A compartment fasciotomy was performed. It is difficult to diagnose a CST in case of muscular contusion as the latter causes symptoms that are similar to CST. A conservative treatment without fasciotomy was carried out by several authors, especially in sportsmen showing a CST following contusion. This conservative treatment implies close monitoring of intramuscular pressures and adjuvant measures (bed rest, holding the thigh at the heart level and oxygenotherapy).

Irreducible traumatic posterior hip dislocation with entrapment and a buttonhole effect.

The authors reported the case of a 27-year-old man who sustained an irreducible postero-lateral traumatic dislocation of the hip with capsular and labral entrapment. Initial X-rays showed only a small acetabular fragment. After two attempts to reduce the hip with muscle paralysis under general anaesthesia failed, the patient was treated by immediate open reduction through a postero-lateral approach. Surgical exploration of the hip revealed a small osteochondral fragment attached to a large piece of labrum and capsule, clogging the acetabulum. The femoral head crossed over the torn capsule with a buttonhole effect. These elements were relieved, the bone fragment was fixed with a 2 mm screw and the capsule was repaired. At the 10-year follow-up, the functional outcome was excellent with a Harris score of 100 points and no signs of necrosis or osteoarthritis. The authors propose a literature review of this uncommon lesion.

Comparative study of femoral diaphyseal morphometry in two male populations, in France and a French West Indies island: an example of clinical relevance of comparative anatomy for orthopedic practice.

Our aim, through a comparative study of two populations, one European and the other Afro-Caribbean, was to find out whether there were differences in radiographic measurements of femoral diaphyseal canal diameter, thickness of the medial and lateral cortex, and global diaphyseal diameter. We studied the nailed femurs of adult males in a population of 54 Europeans and 52 Afro-Caribbeans. Both populations were comparable in terms of age, height and weight. The measurements were taken with a ruler on the narrowest area of the hourglass, the isthmus, on an antero-posterior radiograph. The diameter of the femoral canal was classified into three intervals: <13 mm, 13-14 mm and >14 mm. The femoral canal diameter was significantly larger in the European patients, 14.3 (11-19) versus 13.4 (11-15.6), while the thickness of the lateral cortex was significantly larger in the Afro-Caribbean patients, 8.50 (6-12) versus 7.72 (5.4-11.5). Patient distribution according to the intervals was different in both groups: 59% of the Afro-Caribbeans were in the average interval versus 24.1% of the Europeans. For nearly 53.7% of the Europeans, the diameter of the femoral canal fell in the last interval versus 15.4% of the Afro-Caribbeans. The fact that the femoral canal is narrower in the Afro-Caribbean population may be linked to a thicker lateral cortex. The diameters of the nails used were larger in the European population, 12.6 mm (10-15) versus 12.1 mm (11-14) in the Afro-Caribbean population. The global diameters of both populations' femurs were similar (28.9 mm for the European sample vs. 29 mm). The present study may have an impact on the implants used in the orthopedic surgery (intramedullary nailing, arthroplasty implants). The range of usable implants must be complete and there must be precise pre-operative planning. A study of computed tomography scans could complement our measurements.

Popliteal arteriovenous fistula due to a gunshot injury.

We report the case of a 22-year-old man who presented with a popliteal arteriovenous fistula after a gunshot injury to his right knee. The diagnosis, made in the Emergency Department, was confirmed by arteriography, allowing quick therapeutic intervention. The lesions to the popliteal artery and vein were repaired with a double venous bypass, followed by relieving fasciotomy. Satisfactory clinical results were achieved after 2 months and magnetic resonance imaging revealed normal permeability of the vascular axes. Three years after his operation, our patient has normal function of his knee. The physiopathology, diagnostic difficulties, and management of this type of lesion are discussed with a review of the literature.

Delay in diagnosis of acute on chronic exertional compartment syndrome of the leg.

Exertional compartment syndrome is most commonly described in its chronic form in the young sportive patient. The acute form is a lot rarer and usually only unilateral. We report a case in which a chronic compartment syndrome became acute after intense effort. This was diagnosed rather late due to the lack of knowledge about this syndrome. The necrosis noticed during the fasciotomy was removed by iterative interventions. The wound was left in secondary healing because the patient refused a flap. Upon the patient's last follow-up visit, the wound was healed, but he had a complete deficit in dorsal flexion of the ankle, a foot drop and consequently a step-page gait.

Hip subluxation associated with Pipkin II fracture: an injury to look for before reduction.

Fractures of the femoral head are rare. They usually occur in association with a posterior hip dislocation secondary to a high-energy trauma (motor vehicle accident). We report a case of Pipkin II fracture associated with an irreducible hip subluxation. Clinical signs are poor unlike in posterior hip subluxation. CT scan is important to evaluate the traumatism. The Hardinge approach is relevant in this context of irreducible hip subluxation. The clinical, diagnostic, and therapeutic particularities of this lesion type are discussed.