Interest of including trauma photography in the picture archiving and communication system of a teaching hospital.

Digital imaging is a daily practice in traumatology. Such photographs should remain confidential. However, there is a need for objectivity concerning the circumstances and clinical follow-up for trauma patients. This paper describes how to conserve these photographs within the picture archiving and communication system (PACS) safely as regards identity and confidentiality. A computer converts the photographs into DICOM files. The DICOM image is associated to a reconciliation layer, validated by the physician in charge, and then included in the hospital PACS. This improves transmission from one medical team to another, both initially and after the accident if an expert medical opinion is required. The literature has demonstrated the value of photographs in modern medicine, but the technical and legal challenges are many. They enhance the computerized medical records. Identification, confidentiality and integration in the PACS are obstacles that we have now overcome.

Comparison between percutaneous and traditional fixation of lumbar spine fracture: intraoperative radiation exposure levels and outcomes.

OBJECTIVE: To compare radiation exposure doses and clinical and radiological outcomes between percutaneous pedicular screwing (closed reduction internal fixation [CRIF]) and classical open reduction internal fixation (ORIF) in lumbar spine fracture without neurologic deficit. MATERIALS AND METHODS: Sixty patients (mean age, 42.5 years) were divided into two treatment groups: (Percutaneous) CRIF versus (traditional) ORIF. Screw position and anatomic vertebral reconstruction were checked on routine control X-ray and postoperative CT scan. Study parameters comprised: surgery time, radiation exposure time, radiation dose level for X-ray (DAP) and for CT (DLP),blood loss, length of hospital stay and postoperative pain (VAS). RESULTS: At a mean 25.5 months' follow-up,there were no significant inter-group differences on the epidemiological parameters: age, gender, fracture level, fracture type on the Magerl classification, preoperative local vertebral kyphosis angle, or fracture-to-surgery interval. Effective radiation dose was 3-fold higher in CRIF than in ORIF, but 6-fold lower than for the postoperative CT scan. Postoperative pain on VAS was significantly lower after CRIF, allowing earlier gait resumption and return to work and daily activity. There were no significant differences in length of hospital stay, patient satisfaction, screw malpositioning or postoperative or end-of-follow-up kyphosis angle. CONCLUSION: Percutaneous surgery provided clinical and radiological outcomes strictly comparable to those of open surgery, but with a higher effective radiation exposure dose, including for the medical team and especially for the surgeon. This higher exposure dose, however, is to be relativized by comparison to that of the postoperative CT scan, which involved a much higher exposure dose for the patient. LEVEL OF EVIDENCE: Level IV. Retrospective study.

[Biometric and biomechanic analysis of lumbar posterior facets based on a CT-scan database]. / Analyse biométrique et biomécanique des articulaires lombaires postérieures au sein d'une base de données scanographique.

AIM OF THE STUDY: Our knowledge on anatomy of lumbar spine is based on few cadaver's study with old and few subjects. CT-scan is very precise for lumbar facet's morphology. We have analysed 400 subjects. The aim of this study is to measure different distances, angles and circles to better understand the mechanical function of the lumbar facets. PATIENTS AND METHODS: We have analysed 720 CT-scan. We had 217 men and 183 women with 59 years of mean age. We used native slices of 1.25 mm thick from L1 to S1. We created transversal plan and we put different mark point. We took their coordinates and we have calculated different distances, angles and mechanical circles. We have compared different axis of rotation of the facets. RESULTS: From L1 to S1, the facets goes near to the posterior wall and far from themselves. Moreover, the posterior angle between both facets increase down to the sacrum. The radius of the left side circle and the right one are very closed in 50% of the cases but the three radius are close only in 10% of cases. CONCLUSION: This study based on 400 subjects shows that there is not a unique axis of rotation for both lumbar posterior facets. We have had only 50% of symmetry between both sides whatever the level studied.

Epidemiology of proximal humerus fractures managed in a trauma center.

Proximal humerus fractures (PHF) are osteoporotic fractures that affect women over 70 years of age. Like fractures of the femoral neck they have become a public health concern. As the population ages there is an increase in the number of people in poor general condition with an increased risk of falls on fragile bones. The incidence of these fractures has increased by 15% per year. All patients managed for PHF in our center in the past year were included in this prospective study (prospective cohort study; level 2). Three hundred and twenty-five patients were included with 329 fractures. There was a ratio of two women to one man. At the final follow-up 50 patients had died (15%) and 25 patients were lost to follow-up. The mean age was 70 years old. There were two types of risk factors. The first was fragile bones, and the second was patient specific risk of falls. The severity of the fracture increased with the age of the population. In the study by Charles S. Neer in 1970, 85% of PHF were not or were only slightly displaced, while this category percentage was only 42% in our study. Hospitalization was necessary in 43% of the cases in our study. Surgical management was necessary in 21%. This lack of relationship between the percentage of displaced fractures (58%) and the percentage of surgically treated fractures is a sign of the difficulties of managing this population, which is usually in poor general condition.

Can fluoroscopy radiation exposure be measured in minimally invasive trauma surgery?

Repeated use of X-rays in orthopedic surgery poses the problem of irradiation of patient and caregivers. Seven common minimally invasive bone trauma surgical procedures requiring image intensifier use were investigated: percutaneous K-wire fixation of the wrist, minimally invasive fixation plating of the wrist, percutaneous intramedullary nailing of the tibia and of the femur, short and long trochanteric nail fixation of trochanteric and sub-trochanteric fracture, and percutaneous fixation of thoracolumbar fracture. The study analyzed three parameters: dose area product (DAP), radiation duration, and skin entrance dose (SED). Data were collected from 15 successive implementations of each procedure. The aim of the study was to establish a database for this kind of bone trauma surgery and a hierarchy of the X-ray doses delivered. Percutaneous spinal osteosynthesis involved the highest dose, followed in decreasing order by long trochanteric nailing, femoral nailing, short trochanteric nailing, tibial nailing, wrist K-wire fixation and frontal wrist plate osteosynthesis. One short trochanteric nail procedure delivered the same DAP as 13 wrist K-wire fixation procedures, and one spinal osteosynthesis was equivalent to 13 short trochanteric nail or 174 wrist K-wire procedures. The anatomic area X-rayed appeared to be the main radiation dose factor. A database was established, but actual patient and staff radiation levels remained unknown.

Surgical management of elbow dislocation associated with non-reparable fractures of the radial head.

BACKGROUND: The "terrible triad" of the elbow is the combination of an elbow dislocation, radial head and a coronoid process fracture. Because of a combined sagittal, frontal and transverse instability, these injuries are notoriously difficult to treat. We report our results with a technique for reconstruction of "terrible triad" injuries with either no facture or a type I fracture of the coronoid process in addition to a non-reparable radial head fracture. The hypothesis of this study was that standard surgical treatment of this lesion using a "deep to superficial" stabilisation by a single lateral approach and radial head replacement enables early and reliable functional results. PATIENTS: From June 2004 to January 2007, 13 patients with an average age of 40 years at the date of trauma (range 18-77) underwent reconstruction of a "terrible triad" injury of the elbow with the same technique. The mean follow-up was 25 months (range 15-48). RESULTS: Eighty-four percent of the patients were very satisfied and satisfied. Average flexion was 131 degrees (110-140). Average extension was -11 degrees (-30-0). Average pronation was 72 degrees (40-80). Average supination was 70 degrees (50-80). The grip strength averaged 75% of that of the non-injured side (50-105). All elbows were stable at review. Eight complications occurred. CONCLUSION: Our results suggest that some terrible triad injuries can be successfully managed with deep to superficial stabilisation by lateral approach, consisting in three-dimensional stabilisation done by anterior capsular reinsertion with absorbable anchors, radial head replacement and lateral collateral ligament repair. This standard management provides enough stability to allow early active rehabilitation, preventing post-operative instability and stiffness. This procedure appears to be reliable and reproducible.

[Percutaneous osteosynthesis of lumbar and thoracolumbar spine fractures without neurological deficit: surgical technique and preliminary results]. / Ostéosynthèse percutanée des fractures lombaires et thoracolombaires non neurologiques: technique chirurgicale et résultats préliminaires.

PURPOSE OF THE STUDY: The aim of this work was to study the technique of percutaneous osteosynthesis of lumbar and thoracolumbar spine fractures without neurological deficit and to report preliminary results. MATERIAL AND METHODS: This retrospective study included 15 patients with lumbar or thoracolumbar spine fractures who were treated between January 2004 and January 2006 by percutaneous osteosynthesis. There were seven men and eight women, mean age 36 years (range 16-58 years). The Magerl classification (AO) was A1 (n=4), A2 (n=1), A3 (n=9), B2 (n=1). Levels were T12 (n=1), L1 (n=10), L2 (n=2), L3 (n=1), L4 (n=1). A specific instrument set was used to insert a short fixation using two pedicular screws on either side of the fractured vertebra and two prebent 5.5mm rods introduced with an aiming device. The operation was performed under fluoroscopy. Ten patients wore a removable corset. The upright position was allowed if there were no other injuries. Computed-tomography scans were obtained preoperatively, postoperatively and at two years follow-up. Function was assessed with the Oswestry score. RESULTS: Mean operative time was 108 minutes (range 40-180 minutes). None of the patients with an isolated spinal injury required blood transfusion. Mean hospital stay was 12 days (range 4-28). Results were expressed for 13 patients whose operations were exclusively percutaneous. Mean follow-up was 17 months (range 6-30). The visual analog scale (VAS) was 1.6/10. The mean Oswestry score was 16. Three quarters of the patients resumed their occupational activities. None of the patients was dissatisfied. Mean vertebral kyphosis (VK) improved from 16 to 8.1 degrees , corrected regional angle (CRA) from 12 to 2.5 degrees at last follow-up. Loss of correction at last follow-up was 1.1 degrees for VK and 2.5 degrees for CRA. The rate of pedicle screw malposition was 3.8%. There were no cases of disassembly nor material failure. There were no infections. None of the implants had to be removed. DISCUSSION: Percutaneous osteosynthesis of the spine is technically feasible, but requires considerable experience. Functional and subjective results have been good. The loss of correction at last follow-up has been comparable to that observed with conventional open surgery. This technique is an intermediary method between orthopaedic treatment and conventional surgery. Exact indications must be established. CONCLUSION: Percutaneous osteosynthesis of lumbar and thoracolumbar spine fractures is an attractive therapeutic option. Our results are encouraging. Indications and limitations of this technique must be carefully identified.

[Experience with Poly Ether Ether Ketone (PEEK) cages and locking plate for anterior cervical fusion in the treatment of spine trauma without cord injury]. / Résultats radiologiques des arthrodèses par cages radio-transparentes et plaque antérieure dans le traitement des traumatismes du rachis cervical sans lésions médullaires.

PURPOSE OF THE STUDY: The purpose of this study was to determine whether spinal fusion using radiotransparent cages can be an appropriate treatment for traumatic injury of the cervical spine. MATERIAL AND METHODS: This series included 30 patients aged 17-84 years (average 46 years) treated between October 1999 and June 2003 for traumatic injury of the cervical spine without neurological deficit or cord injury. There were two bifocal cases so that the study concerned 32 fusions. Injuries were: tear drop (n=1), serious flexion sprain (n=8), biarticular dislocation (n=4), serous hyperextension sprain (n=4), dislocation-fracture (n=1), uniarticular fracture (n=7), fracture-separation of the facet joints (n=4), post-traumatic herniation (n=3). For each injury, we measured pre and postoperatively and at last follow-up: the intersomatic angle, anterior displacement, and height of the intersomatic space at the center of the intervertebral disc. All x-rays were read twice, by two independent investigators. In the event of disagreement, the x-rays were read again by a senior surgeon and the main author of this article. Anterior fusion was achieved using a Poly Ether Ether Ketone (PEEK) (32%) and knitted carbon (68%) cage (cologne, Ostapek, Nexis) filled with cancellous bone harvested percutaneously from the iliac crest. The cage was associated with an anterior titanium plate fixation (Senegas, Euros and Orion, Medtronic). A posterior approach was associated if further stability was required (n=4 fusions). All patients were reviewed at minimum five months follow-up. Intersomatic fusion was verified on the standard x-rays (plus stress images and computed tomography at three months). Fusion was considered to be achieved if continuous bone lines crossed the graft and angle measurements remained stable, with the cage in the same position on successive examinations. RESULTS: One patient died from lung cancer five months after spinal fusion. All other patients survived with a mean follow-up of 24 months. Fusion was achieved in all cases, at mean 78 days. The mean intersomatic angle increased from 12 degrees kyposis preoperatively to 13 degrees lordosis postoperatively at last follow-up. Anterior displacement of the fractured vertebral body was 3 mm preoperatively and 0.3 mm postoperatively. Height in the middle of the intersomatic space was 5.3 mm preoperatively and 8.2 mm postoperatively. There were no cases of secondary displacement. DISCUSSION: This study demonstrated that fusion with an intersomatic cage associated with anterior plating can be used in spine trauma victims, providing an outcome as good as in patients with degenerative disease. This method enables nearly anatomic reduction without secondary displacement and fusion in a short delay (which can be explained by the mechanical properties of the assembly and by the use of pure cancellous graft from the iliac crest). There is very little morbidity in our experience. For us, this technique is more reliable than fusion using a tri-cortical iliac crest graft. CONCLUSION: The use of an intersomatic cage is a simple, reliable technique for intersomatic spinal fusion with little morbidity for unstable traumatic injury of the spine without spinal cord injury.

[Inaugural cutaneous metastases of an osteosarcoma: a case report]. / Métastases sous-cutanées révélatrices d'un ostéosarcome du fémur: à propos d'un cas.

Inaugural cutaneous metastasis is exceptional in osteosarcoma. We report a case of a woman with osteosarcoma of the right knee who presented two tumefactions of the scalp at the time of diagnosis. Magnetic resonance imaging identified a high intensity T2 signal in the femur and also a high-intensity signal in the soft tissues. The head scan confirmed the presence of two subcutaneous tumors. Biopsy of the two sites demonstrated the metastatic nature of the cutaneous lesions. The patient was given preoperative and postoperative chemotherapy. Wide resection followed by prosthesis reconstruction was performed. Pulmonary metastases developed and led to two thoracotomy procedures. The patient has remained in remission 22 months. Six cases of cutaneous metastases of osteosarcoma have been reported in the literature. The cutaneous metastases were secondary in five of six cases, occurring after other metastatic localizations had been discovered. The present case is the first published observation of synchronous cutaneous metastases. The duration of remission suggests that cutaneous localizations should be treated like other inaugural metastatic localizations with intensive chemotherapy and wide resection of the primary tumor.

[Acute anterior cruciate ligament repair with combined intra- and extra-articular reconstruction using an iliotibial band with the modified MacIntosh technique: a five-year follow-up study of 50 pivoting sport athletes]. / Reconstruction précoce intra et extra-articulaire du ligament croisé antérieur utilisant le tractus iliotibial selon la technique de MacIntosh modifiée: résultats chez 50 patients pratiquant un sport avec pivots au recul de 5 ans.

PURPOSE OF THE STUDY: Comparisons have been often made between bone-tendon-bone plasty and hamstring tendon four-strand plasty. Whether a lateral tenodesis should be associated with the intra-articular reconstruction and the appropriate time between the accident and the repair remain two topics of debate. We present results obtained in a consecutive series of 50 pivoting sport atheletes reviewed retrospectively. These patients had been treated within eight days of trauma with a modified MacIntosh technique using an iliotibial band. This technique enables lateral tenodesis and reconstruction of the central pivot with only one harvesting site. We searched for responses to two questions: are our results comparable to those in other published series? could this operation be warranted as an emergency procedure? MATERIAL AND METHODS: Fifty patients from a consecutive retrospective series of 62 patients (eight lost to follow-up and four excluded from the analysis) were reviewed by an independent observer at mean follow-up of 5.2 years (range 54.4 to 86.4 months). The ARPEGE and IKDC scoring systems were used. An isokinetic assessment was obtained in 38 patients at one year. The reconstruction technique used an iliotibial band measuring 40-45 mm in width. The lateral reconstruction consisted in section then translation of the lateral intermuscular partition. RESULTS: The overall outcome was scored as follows: IKDC A 38%, B 46%, C 12%, D 4%. Mean residual differential laxity (KT 1000) was 1.86+/-1.74 assessed manually with a negative Lachman in 48% of knees. 88% of the positive tests had been neutralized. Early anatomic failure was noted in two knees with recurrent traumatic tears at 25 and 38 months. Using the ARPEGE scoring system, outcome was excellent in 38%, good in 46%, fair in 12% and poor in 4%. At last follow-up, the level of sports activities was unchanged in 33 patients. Irreducible flexion measuring more than 5 degrees was noted in two patients, and a deficit in flexion greater than 20 degrees in three. One female athlete who had resumed her former sports level presented mobilization under narcosis. None of the patients complained of pain at the harvesting site. There was one case of muscle herniation proximally by wound dehiscence. Mean residual deficit of the quadriceps, measured at twelve months, was 10% at 90 degrees /s; mean residual deficit of the hamstrings at the same speed was 1.3%. DISCUSSION: Our overall results as measured with the IKDC scoring system were comparable with those observed in series using other autologous transplants. The risk of stiffness is greater with early reconstruction, suggesting emergency repair should be considered with caution. Recovery of muscle force demonstrates one of the advantages of using the iliotibial band which does not injure the extensor-flexor system of the knee joint. The fact that none of the patients complained of pain at the harvesting site is a favorable element for rehabilitation and resumed sports activities.

[Hydatid disease of the femoral shaft treated with surgery and hypertonic solution wash-out combined with albendazole]. / Kyste hydatique de la diaphyse fémorale traité par l'association chirurgie, sérum hypertonique et albendazole.

We report a case of pathological fracture of the femoral shaft in a patient presenting a diaphyseal hydatid cyst. Surgical treatment consisted in wide resection followed by washout using a 20% hypertonic saline solution and nail plate fixation. Albendazole was given as adjuvant treatment. Postoperatively, the patient developed rhabdomyolysis with local superinfected necrosis which required early revision to remove the material. At twenty-two months, the local and general course was satisfactory. The pathological fracture healed and no secondary localization could be identified. Echinococcosis serology remained negative. The surgery-hypertonic solution-albendazole combination appears to be an attractive therapeutic solution for bone hydatid disease.

[Ankylosed spine fractures with spondylitis or diffuse idiopathic skeletal hyperostosis: diagnosis and complications]. / Fractures du rachis sur ankylose étendue par spondylarthrite ou hyperostose vertébrale: diagnostic et complications.

PURPOSE OF THE STUDY: Spinal fractures in patients with ankylosing spondylitis or idiopathic skeletal hyperostosis can raise difficult diagnostic and therapeutic problems. Spinal fracture is well known in ankylosing spondylitis but exceptional in diffuse idiopathic skeletal hyperostosis. The purpose of the present work was to identify clinical and radiological features in patients with ankylosing spondylitis, to determine whether similar risks and clinical expression are observed in patients with diffuse idiopathic skeletal hyperostosis, and to present a radiological classification of these fractures. We did not assess therapeutic methods in the present study. MATERIAL AND METHODS: Forty-eight fractures in 48 patients were observed over a period of 17 years. Twenty patients (mean age 62 years) had ankylosing spondylitis and 28 patients (mean age 81 years) had diffuse idiopathic skeletal hyperostosis. A fall was the immediate cause of the fracture in more than half of the patients. No notion of trauma could be identified in six patients. The radiological classification was established as follows; type I open-wedge anterior fracture, type II "sawtooth" fracture, type III occult or radiologically invisible fracture, type IV non-specific fractures comparable to other spinal fractures. A computed tomography was obtained in all patients seen after 1992 and magnetic resonance imaging was performed in case of suspected extradural hematoma. The ASIA classification (as modified by Frankel) was used for cord injuries. Clinical course and complications were noted. RESULTS: Diagnosis was established the day of fracture in 32 patients (12 spondylitis and 20 hyperostosis) and between day 2 and 30 for 16 (8 spondylitis and 8 diffuse idiopathic skeletal hyperostosis). The radiological classification was: type I n=30, type II n=4, type III n=8, type IV n=6 (one odontoid fracture, five compression fractures). Three patients had extradural hematomas (2 spondylitis and 1 hyperostosis). Thirty-four patients (11 spondylitis and 23 hyperostosis) had cord injuries, including 16 with a symptom-free interval. The ASIA classification was: type A n=4, type B n=6, type C n=20, type D n=4. Thirty-two patients died within the first three months after spinal fracture (10 spondylitis and 22 hyperostosis), due to bed rest related complications in 30. One patient died after rupture of an aortic aneurysm. DISCUSSION: Spinal fractures in patients with ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis generally occur spontaneously or after low-energy trauma. Subsequent complications have serious consequences. Late diagnosis either results from missing a radiologically visible fracture or from the presence of an occult "paper thin" fracture. We do not have experience with diagnostic scintigraphy or magnetic resonance imaging. In our opinion, repeating standard x-rays the second and third weeks and use of a spiral scan or multiple spiral scan could provide early diagnosis. CONCLUSION: The possible diagnosis of spinal fracture should be explored very extensively in patients with a symptomatic ankylosed spine who present symptoms compatible with spinal fracture, with or without trauma.

Anatomy of the presacral venous plexus: implications for rectal surgery.

The presacral venous plexus results from anastomoses between the lateral and median sacral veins, and courses into the pelvic fascia covering the anterior aspect of the body of the sacrum. The presacral venous plexus is not directly visible during rectal surgery, and injuries to this plexus may be life-threatening. Dissection of the retrorectal plane or anchoring of the rectum to the sacral promontory as in rectal prolapse surgery exposes the patient to the risk of injury to the presacral venous plexus. The aim of this study was to identify some avascular areas in the anterior aspect of the sacrum in order to lower the occurrence of such injuries during rectal surgery. The pelvis of 10 fresh cadavers was dissected after injection of a colored resin into the inferior vena cava, and the presacral venous plexus was studied. Four avascular tetragonal areas were common to all the specimens. The corners of a square with a side of 3 cm, centered on the anterior aspect of the body of sacrum, were always contained in the avascular areas. The upper side of this square was parallel to a line passing through the sacral promontory, at a 3 cm distance from it. Staples or sutures should be placed in the avascular areas to avoid injuries to the presacral venous plexus.

[Delayed diagnosis of inferior cervical spine injury]. / Délai diagnostique dans les lésions traumatiques du rachis cervical inférieur.

PURPOSE OF THE STUDY: According to data in the literature, traumatic injury of the inferior cervical spine is not recognized in 4.5 to 33% of victims. The purpose of our study was to evaluate the rate of delayed diagnosis, search for causes, and propose a diagnostic approach. MATERIAL AND METHODS: This prospective study included 284 patients recruited by eleven referral centers between November 1999 and March 2001. Each participating center completed a data chart and classified lesions. Exclusion criteria were whiplash without neurological disorder and without imaging anomaly, spinal ankylosis, and trauma more than three weeks before the first examination. RESULTS: Among the 284 patients included, 240 had a unique lesion of the inferior cervical spine, 44 had multiple injuries. In all, 338 spinal lesions were recorded. There were 35 patients with multiple trauma injuries and 95 patients with spinal cord injuries. Time to diagnosis was less than 24 hours for 211 patients (74%), one day to one week for 38 patients (14%), and more than one week for 35 patients (12%). Defective management was noted in 13% of the cases. Late diagnosis was considered to have had a prejudicial effect in nine patients (3%). There was no correlation between time to diagnosis and type of lesion, level of lesion, or presence of multiple injuries. DISCUSSION: Late diagnosis of inferior cervical spine injury can be an inevitable result of the context. This is particularly true for patients with multiple injuries or patients with purely discal or ligament injuries whose first manifestations occur late after the trauma. Beyond these specific situations, there is no logical explanation for late diagnosis other than insufficient diagnostic management. Spinal injury should always be suspected in trauma victims and the initial neurological status must be noted. If the subject is conscious, plain x-rays should be obtained in the event of pain in the cervical spine. A computed tomography is the exploration of choice. Dynamic views should be performed in all cases to search for pure ligament injury. The correct time for such explorations can only be determined on an individual basis. If the patient is unconscious, standard procedure includes x-ray of the cervical spine, and computed tomography of the skull-spine junction and the cervico-thoracic spine. Widespread systematic use of spiral and multiple array computed tomography should limit the number of late diagnoses. CONCLUSION: Late diagnosis of inferior cervical spine injury is probably not uncommon. Improved management can be achieved through better medical awareness, better knowledge of cervical spine injuries, and routine imaging in application of the rule of prudence.

Anatomical study of the blood supply of the coxal bone: radiological and clinical application.

The aim of this work was to study the arterial blood supply of the coxal bone in order to optimize radiological embolization and to minimize the risk of postoperative osteonecrosis. Ten fresh cadavers were dissected after intra-arterial injection of colored resin. All the collateral vessels running to this bone were described and counted. On 25 dry bones, the vascular foramina were measured with the aid of a millimetric gauge and a vascular map was created. The posterior part of the ilium appears to be twice as well vascularized as the anterior part. Fractures of the posterior arch of the pelvis are theoretically more hemorrhagic. The presence of the iliolumbar artery in contact with the sacroiliac joint increases the risk with open book or shearing fractures. The artery of the ischium, a collateral of the pudendal artery, supplies the posterior and lateral parts of the acetabulum and the artery of the roof of the acetabulum, its superior and lateral parts. The branches of the anterior and posterior divisions of the obturator artery supply the superior part of the surroundings of the obturator foramen and the antero-inferior and postero-inferior parts of the acetabulum. The Kocher approach may injure the artery of the ischium. Letournel's extended lateral approach and Mears' triradiate approach may injure the artery of the ischium and the artery of the roof of the acetabulum. The risk of osteonecrosis appears to be theoretically increased if one adds an endopelvic approach. The anterior approach to the acetabulum appears to be that which theoretically leads to the least devascularization. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer Link server located at http://dx.doi.org/10.1007/s00276-002-0029-2.

[Videoscopic retropleural and retroperitoneal approach to the thoracolumbar junction of the spine]. / Voie rétro séreuse du rachis à l'étage thoraco-lombaire sous contrôle vidéoscopique.

PURPOSE OF THE STUDY: A minimally invasive anterior approach has been developed for the thoracolumbar junction of the spine. The aim of this study was to evaluate the possibilities of videoscopic treatment of fractures and malunions of the thoracolumbar junction and to report the first results obtained with this technique. MATERIAL AND METHODS: Video-assisted surgery was performed in eleven patients using costal resection and a retropleural and retroperitoneal approach. Anterior arthrodesis was performed in all cases, four with anterior instrumentation. The indications were trauma for six patients and malunion for five. RESULTS: Mean follow-up was 17.4 months. For malunion patients, the mean angular gain was 22.4 degrees. Radiological anterior fusion was achieved in all cases except one. The mean angular loss was 5.7 degrees. DISCUSSION: The surgeon can control the procedures by direct vision, while the assistant follows the operation on the video display screen. The upper par of L1 can be reached via a supradiaphragmatic retropleural approach, while a larger exposure is possible if the insertions of the diaphragm are released and the retroperitoneal space is opened. The crus does not have to be sectioned to expose the lateral part of the thoracolumbar vertebrae. Possible complications are similar to those which can be observed with open procedures. CONCLUSION: The videoscopic approach enables the exposure of throacolumbar junction with a smaller parietal lesion than with open procedures. It enables arthrodesis procedures with corporectomay, angular correction and anterior osteosynthesis.

Traumatic rotatory displacement of the lower cervical spine.

The authors describe the classification for traumatic rotary injuries of the cervical spine. The classification is based on a review of 306 severe lower cervical spine injuries observed in 255 patients between 1980 and 1994. Traumatic rotatory displacements (TRD) represented 39% of the 306 severe injuries. Three different lesions were observed: unilateral facet fractures, fracture-separation of the articular pillars, and unilateral facet dislocations.

Five years' experience of the retroperitoneal lumbar and thoracolumbar surgery.

Retroperitoneal videoscopic spine surgery has been developed in our department since 1994. It has been used not only at the lumbar, but also at the thoracolumbar and lumbosacral level. Thirty-eight patients have been operated on. We have performed 12 thoracolumbar approaches, 23 lumbar approaches, and 3 retroperitoneal lumbosacral approaches. In every case, a video-assisted technique has been employed. These techniques have been used for anterior grafting in 18 cases of fracture, for corporectomy and grafting with or without anterior osteosynthesis in 6 cases of malunion, for cage implantation or isolated grafting in 10 cases of degenerative disc disease, and for the treatment of 4 cases of spondylodiscitis. Results were satisfactory for every type of pathology. The complications related to the approach were the same as those seen with open surgery; however, the videoscopic approach seems to us less invasive, with cosmetic benefit, less blood loss, and more rapid recovery. A video-assisted technique appears to be a good compromise between videoscopic technique and open surgery. With the development of these techniques, few indications remain for open anterior surgery on the lumbar spine in our opinion.

[Percutaneous osteosynthesis of pelvic fractures with CT control]. / Ostéosynthése percutanée des fractures du bassin sous contrôle tomodensitométrique.

Pelvis fractures, most often multiple, are frequently unstable. Orthopedic treatment is hardly bearable (traction in bed sometimes up to 45 days), the open reduction and internal fixation (ORIF) is heavy. Percutaneous fluoroscopy guided fixation lacks precision in depth. Percutaneous screw fixation with CT scan control answers these drawbacks and represents a quick solution, with few hazard when performed by a trained team and allows a very early resumption of standing.