Long-term follow-up of cardiac arrest survivors: Protocol of the DESAC (Devenir des survivants d'Arrets Cardiaques) study, a French multicentric prospective cohort.

Background: While the short-term prognosis of cardiac arrest patients - nearly 250,000 new cases per year in Europe - has been extensively studied, less is known regarding the mid and long-term outcome of survivors. Objective: The aim of the DESAC study is to describe mid- and long-term survival rate and functional status of cardiac arrest survivors, and to assess the influence of pre and intra hospital therapeutic strategies on these two outcomes. Methods: Between Jul 2015 and Oct 2018, adult patients over 18 years who were discharged alive from any intensive care units (public and private hospitals) in the Ile-de-France area (Paris and suburbs, France) after a non-traumatic cardiac arrest were screened for participation in this multicentric study. Survivors were included after they signed (or the proxies) an informed consent before discharge during initial hospitalisation. We calculated that including 600 patients in total would allow an 80% power to demonstrate a 2 years survival rate difference of 10% between patients who did and those who did not receive therapeutic hypothermia after resuscitation. Pre- and in-hospital data related to the circumstances surrounding the event and to the therapeutic interventions (such as cardio-pulmonary resuscitation, defibrillation, emergent coronary revascularization, neuroprotective therapeutics) were collected. After discharge, patients were interviewed at 3 months, 6 months and every year thereafter for a minimum follow-up of 26 months and a maximum follow-up of 48 months. Information on vital status, occurrence of cardiovascular events, medications and a comprehensive assessment of the functional status (qualitive of life as assessed by the Short-Form General Health Survey (SF36) scale, activities of daily living (ADL) scale, neurological Cerebral Performance Categories (CPC) and Overall Performance Categories (OPC) scales, socio-professional activities) were collected at follow-up interviews. Discussion: The DESAC study should provide important information regarding several dimensions of the mid and long-term prognosis of cardiac arrest survivors and on the benefit (and potentially harm) of early therapeutic strategies.

Clinical and radiological outcomes of a cohort of 9 patients with anatomical fractures of the cuboid treated by locking plate fixation.

INTRODUCTION: Cuboid fractures are very rare. Hence, their treatment has not been standardized. Advances in imaging techniques, particularly three-dimensional computed tomography (3D CT), and the introduction of cuboid-specific plates has improved the care of these injuries. The aim of this study was to determine the radiological and clinical outcomes of anatomical reconstruction of comminuted cuboid fractures with a locking plate. HYPOTHESIS: Fixation of comminuted cuboid fractures with a cuboid-specific locking plate leads to stable anatomical reduction and good functional outcomes. MATERIAL AND METHODS: This was a retrospective study of 9 consecutive cases of comminuted cuboid fracture treated at a single hospital between January 2009 and December 2015. A 3D CT scan was performed preoperatively with subtraction of the posterior tarsal bone to allow the articular facets to be viewed and analyzed. Fracture fixation was done with a Locking Cuboid Plate (DePuy Synthes™). Associated lesions in the foot were treated during the same procedure. The patients were reviewed by an independent observer who performed a clinical examination, and determined the AOFAS and Maryland Foot Score. The success of the reconstruction was determined by comparing the parameters on weight-bearing X-rays views between the fixed and non-operated cuboid. RESULTS: The mean follow-up was 4.1 years (range 1-6). The Maryland Foot Score was 93.1 [86-100] and the AOFAS was 91.9 [82-100]. The reconstruction was anatomical and long lasting in all 9 cases. There was no foot misalignment in the frontal plane, based on the radiographs (hindfoot axis 5.5° [0-9]). The mean Djian-Annonier angle was 123.9° [108-130]. CONCLUSION: Cuboid fractures can be treated effectively through appropriate imaging and with a cuboid-specific locking plate as evidenced by very good midterm clinical and radiological outcomes in this study. LEVEL OF EVIDENCE: IV Retrospective study.

Reconstruction of large diaphyseal bone defect by simplified bone transport over nail technique: A 7-case series.

Reconstruction of large diaphyseal bone defect is complex and the complications rate is high. This study aimed to assess a simplified technique of segmental bone transport by monorail external fixator over an intramedullary nail.A prospective study included 7 patients: 2 femoral and 5 tibial defects. Mean age was 31years (range: 16-61years). Mean follow-up was 62 months (range: 46-84months). Defects were post-traumatic, with a mean length of 7.2cm (range: 4 to 9.5cm). For 3 patients, reconstruction followed primary failure. In 4 cases, a covering flap was necessary. Transport used an external fixator guided by an intramedullary nail, at a rate of 1mm per day. One pin was implanted on either side of the distraction zone. The external fixator was removed 1 month after bone contact at the docking site. Mean bone transport time was 11 weeks (range: 7-15 weeks). Mean external fixation time was 5.1months (range: 3.5 to 8months). Full weight-bearing was allowed 5.7months (range: 3.5-13months) after initiation of transport. In one patient, a pin had to be repositioned. In 3 patients, the transported segment re-ascended after external fixatorablation, requiring repeat external fixation and resumption of transport. There was just 1 case of superficial pin infection. Reconstruction quality was considered "excellent" on the Paley-Marr criteria in 6 cases. The present technique provided excellent reconstruction quality in 6 of the 7 cases. External fixation time was shorter and resumption of weight-bearing earlier than with other reconstruction techniques, notably including bone autograft, vascularized bone graft or the induced membrane technique. Nailing facilitated control of limb axis and length. The complications rate was 50%, comparable to other techniques. This study raises the question of systematic internal fixation of the docking site, to avoid any mobilization of the transported segment. The bone quality, axial control and rapidity shown by the present technique make it well-adapted to reconstruction of diaphyseal bone defect. LEVEL OF EVIDENCE: Four-case series.

Percutaneous reduction of proximal radius fracture in adults. A 12-case series.

Fractures of the head or neck of the radius account for 5% of elbow fractures in adults. Treatment varies between authors. We report a retrospective series of 12 cases of percutaneous reduction of Mason II radial head fracture, without internal fixation. All fractures consolidated, without secondary displacement. There were no postoperative complications. Mean ranges of motion were 136° flexion-extension and 175° pronation-supination. Mean QuickDASH score was 11. Results in the present series were at least comparable to those for other techniques, validating percutaneous treatment as a solution for radial head fracture. TYPE OF STUDY: Case series. LEVEL OF EVIDENCE: IV.

[Pilon fractures]. / Pilonfrakturen.

Pilon fractures are articular fractures of the distal tibia which involve the weight bearing part of the ankle joint. Assessment of the fracture is carried out with computed tomography and evaluation of the skin and soft tissue damage. In joint-preserving surgical reconstruction, treatment of the soft tissue damage has priority. The surgical approaches are preferably local and when necessary multiple (up to three) and performed simultaneously but the localization also depends on the trauma-induced damage. The surgical strategy includes joint distraction, sequential joint reconstruction and joint axis correction as well as early non-weight bearing joint mobilization.

An original internal fixation technique by tension band wiring with steel wire in fractures of the coronoid process.

Fractures of the coronoid process, which is a key element in anterior elbow joint stability, represent 14% of proximal ulnar fractures. Optimal treatment should stabilize all fractures associated with elbow instability. Different techniques have been described: suture repair, screws, plates… We propose a series of 5 patients who were treated with an original, easy, tension band wiring fixation technique using steel wire with easy hardware removal.

Internal fixation of complex fractures of the tarsal navicular with locking plates. A report of 10 cases.

INTRODUCTION: Tarsal navicular fractures are rare and treatment of comminuted fractures is especially difficult. Since 2007, the authors have had access to 3D reconstruction from CT scan images and specific locking plates, and they decided to evaluate whether these elements improved management of these severe cases. MATERIALS AND METHODS: Between 2007 and 2011, 10 comminuted tarsal navicular fractures were treated in a prospective study. All of the fractures were evaluated by 3D reconstruction from CT scan images, with suppression of the posterior tarsal bones. The surgical approach was chosen according to the type of lesion. Reduction was achieved with a mini-distractor when necessary, and stabilized by AO locking plate fixation (Synthes™). Patient follow-up included a clinical and radiological evaluation (Maryland Foot score, AOFAS score). Eight patients underwent postoperative CT scan. RESULTS: All patients were followed up after a mean 20.5 months. Union was obtained in all patients and arthrodesis was not necessary in any of them. The mean Maryland Foot score was 92.8/100, and the AOFAS score 90.6/100. One patient with an associated comminuted calcaneal fracture had minimal sequella from a compartment syndrome of the foot. DISCUSSION: The authors did not find any series in the literature that reported evaluating tarsal navicular fractures by 3D reconstruction from CT scan images. The images obtained after suppression of the posterior tarsal bones systematically showed a lateral plantar fragment attached to the plantar calcaneonavicular ligament, which is essential for stability, and which helped determine the reduction technique. Locking plate fixation of these fractures has never been reported. CONCLUSION: Comminuted fractures of the tarsal navicular were successfully treated with specific imaging techniques in particular 3D reconstructions of CT scan images to choose the surgical approach and the reduction technique. Locking plate fixation of the navicular seems to be a satisfactory solution for the treatment of these particularly difficult fractures. LEVEL OF EVIDENCE: Level IV.

Trabecular microarchitecture in established osteoporosis: relationship between vertebrae, distal radius and calcaneus by X-ray imaging texture analysis.

INTRODUCTION: Osteoporosis is an alteration of bone mass and microarchitecture leading to an increased risk of fractures. A radiograph is a 2D projection of the 3D bone network exposing a texture, that can be assessed by texture analysis. We compared the trabecular microarchitecture of the spine, radius and calcaneus in a series of osteoporotic cadavers. MATERIALS AND METHODS: Thirty-four cadavers (11 men, 23 women), mean age 85.2±2.1years, were radiographed from T4 to L5 to identify those with vertebral fractures (FV). Non-fractured vertebrae (NFV), radius and calcaneus were taken and analyzed by densitometry, radiography and texture analysis under run-length, skeletonization of the trabeculae, and fractal geometry. RESULTS: Six subjects (five women, one man) were selected, mean age 82.5±5.5years. Twelve calcanei and 10 radii were taken. Two radii were excluded. The texture of NFV was significantly correlated (P<0.01) with that of the radius for horizontal run-lengths. No relationship between the texture of NFV and calcaneus was found. DISCUSSION: In the horizontal direction (perpendicular to the stress lines), the microarchitecture of NFV and radius showed a disappearance of the transverse rods anchoring the plates. Due to its particular microarchitecture, the calcaneus is not representative of the vertebral status. CONCLUSION: Bone densitometry provides no information about microarchitecture. Texture analysis of X-ray images of the radius would be a minimally invasive tool, providing an early detection of microarchitectural alterations. LEVEL OF EVIDENCE: IV retrospective study.

[Continuous infusion of ropivacaine has no effects on pyrolytic implant: a preliminary study in rats]. / La diffusion continue de ropivacaïne in situ n'a pas d'effet sur le pyrocarbone : une étude in vivo chez le rat.

The aim of the study is to analyse the effects of ropivacaïne on a pyrolytic implant in bone surgery. Ten rats were operated with a pyrolytic implant placed at the hip after femoral head resection: five cases with continuous infusion of ropivacaïne and five cases with continuous infusion of sterile water. Six days after, all the implants were analysed: weight, length, width, thickness and global design. This work showed that ropivacaïne can be use as continuous infusion with pyrolytic implant. Other studies in human surgery are necessary.

Treatment of complex fractures of the distal radius: a prospective randomised comparison of external fixation 'versus' locked volar plating.

The traditional treatment of severely impacted fractures of the distal radius involves bridging external fixation and maintaining reduction by applying continuous traction. The recent technique using fixed-angle screws within volar plates is reported restore the radial length and the articular profile whilst avoiding joint distraction. It is also believed to produce better and quicker clinical results. To test these claims, we carried out a randomised controlled comparison of the efficiency of external fixation (EF) 'versus' open reduction and internal fixation (ORIF) in treating severely impacted fractures of the distal radius. A total of 39 patients were treated with EF, eventually associated with percutaneous pinning, whereas 36 underwent ORIF with a locked volar plate. There was no significant difference in the two groups with regard to changes in the ulnar variance. Articular reduction was poor in two patients in the EF group with residual step-offs exceeding 2mm; another patient of the EF group suffered a secondary loss of reduction, healing with a severe articular malunion (>2mm). By contrast, articular reduction was satisfactory in all the patients of the ORIF group. The clinical results on the Green and O'Brien rating were significantly better in the ORIF group than in the EF group (p<0.01 at 6 weeks, p<0.05 at 6 months). Nevertheless, open reduction and volar plating did not yield better subjective results than EF. However, although not statistically significant, patients treated by ORIF seemed to resume their usual activities quicker than those treated with EF, suggesting that this technique may be adapted to a greater extent in the case of active, young individuals.

Isolated interfragmentary compression for nonunion of humeral shaft fractures initially treated by nailing: A preliminary report of seven cases.

INTRODUCTION: Plating with bone grafting is considered the gold standard treatment for nonunion of humeral shaft fractures. However, this complex procedure involves multiple risks. The aim of this study is to evaluate an alternative treatment using isolated axial interfragmentary compression for the dynamisation of humeral shaft nonunion after retrograde locked nailing. MATERIALS AND METHODS: Between January 2000 and May 2009, 124 humeral shaft fractures were treated in our trauma department with retrograde locked nailing using the unreamed humeral nail (UHN(®), Synthes, Paoli, PA, USA). Nonunion occurred in seven patients (5.6%) - five females and two males, mean age 44 years (range: 17-73 years). The nonunion was treated by applying isolated secondary interfragmentary compression. Mean follow-up was 43 months (range: 8-74 months). The Rommens score and the disabilities of the arm, shoulder and hand (DASH) score were used to evaluate the global functioning of the upper limb. RESULTS: The compression procedure was successful in all seven cases. In each case, the union occurred without any complications in 3-5 months. The mean DASH score was 25/100 (range: 8.3-60.8/100). The Rommens score was judged excellent for five of the seven patients but two were rated moderate. One of these suffered from complex regional pain syndrome type II since the fracture, and another developed a stiff shoulder 6 months after trauma. CONCLUSION: Isolated secondary interfragmentary compression appears to be a simple and successful procedure in cases of humeral nonunion.

Two-stage reconstruction of post-traumatic segmental tibia bone loss with nailing.

INTRODUCTION: Treatment of lower extremity segmental bone loss is difficult. Masquelet et al. proposed a two-stage technique: first, debridement and filling of bone loss with an acrylic spacer; second, bone reconstruction by filling with cancellous bone in the space left free (following cement removal) inside the so-called self-induced periosteal membrane. In the originally described technique, the fracture site is stabilized by an external fixator, which remains in place throughout the bone healing process, i.e., often longer than 9 months with all the known disadvantages of this type of assembly. Following the principle of two-stage reconstruction, we modified the technique by reconstructing around an intramedullary-locking nail placed in the first stage. HYPOTHESIS: This technique prevents the mechanical complications related to external fixator use and provides faster resumption of weight-bearing. PATIENTS AND METHODS: Twelve patients were operated for segmental tibial bone loss greater than 6cm resulting from injury (four cases) or aseptic necrosis (one case) or septic necrosis (seven cases). All the patients were operated on in an emergency setting and the first stage was performed before the 2nd week. A free muscle flap (ten patients) or a pediculated fasciocutaneous flap (two patients) was necessary during this first step to cover the site and provide good conditions for secondary bone growth. The follow-up was 39.5 months (range, 12-94 months). RESULTS: Complete weight-bearing was resumed at a mean 4 months. After the second step, all the patients except one had apparently healed (complete weight-bearing with no pain). Five septic complications occurred after the second step, in one case leading to reconstruction failure. Four other patients had infectious complications successfully treated (as of the last follow-up) either by changing the nail in two cases or by prolonged antibiotic therapy in two other cases, with no graft loss. DISCUSSION: The use of the intramedullary nail facilitates the Masquelet technique by allowing the patient to resume weight-bearing more quickly and avoiding secondary fractures. However, the risk of sepsis remains high but can be controlled without compromising the final bone union in four cases out of five. LEVEL OF EVIDENCE: Level IV. Retrospective 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.

A prospective study of a new locking plate for proximal humeral fracture.

Displaced and unstable extra-articular fractures of the proximal humerus are treated by operative reduction and fixation using various techniques such as fixed plates and intramedullary implants. This prospective study evaluates the clinical efficacy of a novel implant that is attached to the humeral head with fixed-angle locking screws. Between October 2002 and November 2005, 99 people (mean age 62.8 years) with proximal humeral fractures received treatment involving this plate in our department. The mean follow-up time was 17.8 months. Outcome was assessed with radiography, the Constant-Murley (C-M) shoulder evaluation and the Disabilities of the Arm, Shoulder and Hand (DASH) score. The mean C-M score was 64.95% and the mean DASH score was 30.1 points. Outcome was judged excellent in 51%, good in 19%, moderate in 19% and poor in 11% of cases.

[Locked volar plating for complex distal radius fractures: maintaining radial length]. / Ostéosynthèse par plaque antérieure verrouillée des fractures complexes de l'extrémité distale du radius: contribution au maintien de la longueur radiale.

PURPOSE OF THE STUDY: Maintaining radial length, likely to be the main challenge in the treatment of complex distal radius fractures, is necessary for complete grip-strength and pro-supination range recovery. In spite of frequent secondary displacements, bridging external-fixation has remained the reference method, either isolated or in association with additional percutaneous pins or volar plating. Also, there seems to be a relation between algodystrophy and the duration of traction applied on the radio-carpal joint. Fixed-angle volar plating offers the advantage of maintaining the reduction until fracture healing, without bridging the joint. MATERIAL AND METHODS: In a prospective study, forty-three consecutive fractures of the distal radius with a positivated ulnar variance were treated with open reduction and fixed-angle volar plating. Results were assessed with special attention to the radial length and angulation obtained and maintained throughout treatment, based on repeated measurements of the ulnar variance and radial angulation in the first six months postoperatively. RESULTS: The correction of the ulnar variance was maintained until complete recovery, independently of initial metaphyseal comminution, and of the amount of radial length gained at reduction. Only 3 patients lost more than 1 mm of radial length after reduction. The posterior tilt of the distal radial epiphysis was incompletely reduced in 13 cases, whereas reduction was partially lost in 6 elderly osteoporotic female patients. There was 8 articular malunions, all of them less than 2 mm. Secondary displacements were found to be related to a deficient locking technique. Eight patients developed an algodystropy. The risk factors for algodystrophy were articular malunion, associated posterior pining, and associated lesions of the ipsilateral upper limb. CONCLUSION: Provided that the locking technique was correct, this type of fixation appeared efficient in maintaining the radial length in complex fractures of the distal radius. The main challenge remains the reduction of displaced articular fractures. Based on these results, it is not possible to conclude that this method is superior to external fixation.

[Retrograde locked nailing of humeral shaft fractures: a prospective study of 58 cases]. / Traitement des fractures récentes de la diaphyse humérale par enclouage centromédullaire verrouillé rétrograde: une étude prospective de 58 cas.

PURPOSE OF THE STUDY: Appropriate treatment for humeral shaft fractures remains a debated issue. Among the classical osteosynthesis techniques proposed, closed nailing was adapted to the humerus rather late, using the anterograde method. Use of retrograde nailing, which spares the rotator cuff, is more recent. The purpose of this study was to report outcome in 58 humeral shaft fractures in adults treated using the universal humeral nail between January 2000 and December 2003. MATERIAL AND METHODS: This work was limited to recent shaft fractures in adults with non-pathological bones. The fractures included were all situated between the insertion of the pectoralis major and a point situated 2 cm above the apex of the olecraneum fossa. The series included 58 patients with 58 humeral shaft fractures. All fractures were closed except four (Gustilo type I and II). Two patients presented preoperative radial paralysis which was not considered to be a contraindication for retrograde locking nailing. The paralysis recovered in both patients, after neurolysis performed during the nailing procedure in one. Osteosynthesis was performed without opening the fracture focus under fluoroscopic control using a static locking nail inserted retrograde in patients in the supine position. RESULTS: There were two early deaths unrelated to the method. Healing was obtained in the surviving patients within fifteen weeks on average. Bone healing was primary in 53 patients and after secondary compression in three. At last follow-up, shoulder motion was normal in 88% of patients and elbow motion in 91%. The Rommens functional score was good in 84%. Complications included three cases of spontaneously regressive postoperative radial paralysis, three cases of reflex dystrophy including two which regressed, and two cases of humeral palette fracture requiring surgical osteosynthesis. The proximal screws were removed in six patients because of pain or migration. To date, implants have been removed in three patients without problem. There were no infections. CONCLUSION: Retrograde insertion of this nail facilitates treatment of humeral shaft fractures by allowing immediate joint motion and the advantages of closed reduction: no infection, no late bone healing requiring conversion to another method of fixation. The residual technical problems concern proximal nailing and nail introduction.

[The serratus anterior free flap in limb reconstruction. About 30 cases]. / Le lambeau de serratus anterior en chirurgie reconstructrice du membre inférieur. A propos de 30 cas.

Between 2001 and 2003, 30 serratus anterior free flaps have been realized in our unit for reconstruction of lower limb. The flaps were indicated for repair of traumatic soft tissue defect in 19 cases, for chronic wound in six cases, for purpura fulminans in two cases, for pressure sore in one case and after tumor resection in 1 case. There were 29 patients: 25 males and four females. They ranged in age from 5 to 64 years. The size of the soft tissue defects ranged between 15 and 180 cm(2). Four different types of serratus anterior flaps were used: 20 muscle flaps ; four myocutaneous flaps ; five costo-osteomuscular flap ; one costo-osteomyocutaneous flap . In all cases we used osteo flap (8 th rib) in order to restore bone defect, which ranged from 9 to 15 cm. Necrosis occurred in two flaps because of venous thrombosis. The functional outcome was good for all patients and the aesthetic sequelae at the donor site were considered as minor. The serratus anterior flap can be used in many different ways: different kinds of flaps (osteo-cutaneous-muscle); very variable size of flap (15 to 180 cm(2) in our series) , different length of pedicle possible. Because of his versatility and his absence of major functional or aesthetic sequelae the serratus anterior free flap has become day by day our favourite option in limb reconstruction.

Anatomic relations between the cephalic vein and the sensory branches of the radial nerve: How can nerve lesions during vein puncture be prevented?

UNLABELLED: The cephalic vein of the forearm is often used for IV catheters because of its ease of access for peripheral venous cannulation. But its close relation to the sensory branch of the radial nerve sometimes causes it to be damaged when the vein is cannulated. Our anatomic study conducted on 33 specimens confirmed the risk of nerve lesion. However, it is impossible to define a safe zone, because of the randomly located nerve and vein crossing zones, where the iatrogenic risk of damaging the radial nerve is maximum. We suggest that to avoid incidents, the cephalic vein should be punctured above the emergence of the sensory branch of the radial nerve, e.g., at least 12 cm above the level of the styloid process of the radius. IMPLICATIONS: We attempted to determine the relationship between the cephalic vein and the sensory branch of the radial nerve at the wrist to help prevent lesions of the radial nerve when the cephalic vein is cannulated. We examined the anatomy of 33 postmortem specimens and suggest that puncture of the cephalic vein 12 cm or more proximal to the styloid process can prevent radial nerve lesions.

Descriptive anatomic study of the fourth perforating artery of the femoral system.

The existence of the fourth perforating artery of Paturet [7], a collateral branch of the superficial femoral artery in its lower third, is the subject of much debate. This artery has so far only been the subject of radio-anatomic descriptions based on arteriographies carried out within the context of arteriopathy of the lower limbs. We present a descriptive anatomic study of this artery based on 14 observations on 32 dissections. Three types of approach were carried out: exposure of the artery of the femoral quadriceps muscle up to its ending in the vastus lateralis; a lateral "orthopaedic" approach to the lower third of the femur; and a "vascular" approach by a medial incision to the femoro-popliteal axis in the lower third of the thigh. Its main relations are described, passing in front of the superficial femoral vein and then behind the femur before ending at the vastus lateralis muscle. These relations explain the possibility of anastomoses with collateral or terminal branches of the deep femoral artery (vastus lateralis artery, third perforating artery). The fourth perforating artery of Paturet [7] must be protected in traumatologic and vascular surgery. It is the main collector of vascular anastomoses between the deep femoral artery and the femoro-popliteal axis in the event of proximal occlusion of the superficial femoral artery. Its removal, in such a case, can aggravate an underlying arteriopathy.

Anatomic and radioanatomic study of the lateral genicular arteries: application to prevention of postoperative hemarthrosis after arthroscopic lateral retinacular release.

Arthroscopic lateral retinacular release can be complicated by hemarthrosis in 10 to 18% of cases. The vascular structures involved are the lateral vascular pedicles of the knee. This study examines the topography of these pedicles. Anatomic and radioanatomic studies carried out in 50 specimens defined the route of the vascular pedicles at the lateral aspect of the knee. From the measurements carried out, we noted the relative homogeneity of the routes taken by the different proximo-lateral vascular pedicles, which are highly vulnerable, and the variability of the disto-lateral arterial routes. A tracing-paper study identified two distinct routes for the disto-lateral vascular pedicle and evaluated the risk of injury to it in surgical approaches to the lateral aspect of the knee. Finally, the topographic data of the study suggest the possibility of preventive hemostasis of the proximo-lateral pedicle via a minimal approach close to the patella. Furthermore, it seems possible to avoid cutting the disto-lateral pedicle if it is localised by cutaneous trans-illumination at the beginning of the operation.