Sacroiliac joint syndrome after lumbosacral fusion.

INTRODUCTION: One-third of low back pain cases are due to the sacroiliac (SI) joint. The incidence increases after lumbosacral fusion. A positive Fortin Finger Test points to the SI joint being the origin of the pain; however, clinical examination and imaging are not specific and minimally contributory. The gold standard is a test injection of local anesthetic. More than 70% reduction in pain after this injection confirms the SI joint is the cause of the pain. The aim of this study was to evaluate the decrease in pain on a Numerical Rating Scale (NRS) after intra-articular injection into the SI joint. We hypothesised that intra-articular SI injection will significantly reduce SI pain after lumbosacral fusion. METHODS: All patients with pain (NRS>7/10) suspected of being caused by SI joint syndrome 1 year after lumbosacral fusion with positive Fortin test were included. Patients with lumbar or hip pathologies or inflammatory disease of the SI joint were excluded. Each patient underwent a 2D-guided injection of local anesthetic into the SI joint. If this failed, a second 2D-guided injection was done; if this also failed, a third 3D-guided injection was done. Reduction of pain on the NRS by>70% in the first 2 days after the injection confirmed the diagnosis. Whether the injection was intra-articular or not, it was recorded. Ninety-four patients with a mean age of 57 years were included, of which 70% were women. RESULTS: Of the 94 patients, 85 had less pain (90%) after one of the three injections. The mean NRS was 8.6/10 (7-10) before the injection and 1.7/10 after the injection (0-3) (p=0.0001). Of the 146 2D-guided injections, 41% were effective and 61% were intra-articular. Of the 34 3D-guided injections, 73% were effective and 100% were intra-articular. DISCUSSION: This study found a significant decrease in SI joint-related pain after intra-articular injection into the SI joint in patients who still had pain after lumbosacral fusion. If this injection is non-contributive when CT-guided under local anesthesia, it can be repeated under general anesthesia with 3D O-arm guidance. This diagnostic strategy allowed us to confirm that pain originates in the SI joint after lumbosacral fusion in 9 of 10 patients. CONCLUSION: If the first two CT-guided SI joint injections fail, 3D surgical navigation is an alternative means of doing the injection that helps to significantly reduce SI joint-related pain after lumbosacral fusion. LEVEL OF EVIDENCE: IV, retrospective study.

Early mortality and morbidity of odontoid fractures after 70 years of age.

INTRODUCTION: Odontoid fractures are very common in older adults and are associated with a high mortality rate. The aim of this study was to evaluate the outcomes after conservative treatment of non-displaced odontoid fractures and surgical treatment of displaced fractures in patients older than 70 years. It was hypothesized that early mortality of displaced fractures is higher than in non-displaced fractures. MATERIAL AND METHODS: This was a single-center retrospective observational study of odontoid fractures (type II in the Anderson and Alonzo classification) in patients older than 70 years that occurred between 2014 and 2017. Conservative treatment with immobilization for 3 months was proposed when the fracture was displaced less than 2 mm (non-displaced fracture group). Surgical treatment in the form of anterior screw fixation was proposed when the fracture displacement was more than 2 mm (displaced fracture group). The primary endpoint was the mortality rate at 3 months. RESULTS: The study included 79 patients (46 women) who had a mean age of 85 years (70-105). The 3-month mortality in the entire cohort was 27% and the 1-year mortality was 30%. Conservative treatment was provided to the 36 patients with non-displaced fractures. The 3-month mortality rate in this group was 11%. A displaced fracture occurred in 43 patients: 17 were treated surgically by anterior screw fixation; 20 could not be operated on because of anesthesia contraindications and 6 died within 24hours of the fracture event. The 3-month mortality rate in this group was 40%; 3 of the 17 operated patients died from postoperative respiratory complications; 8 of the 20 patients with contraindications died, in addition to the 6 that died soon after the fracture occurred. DISCUSSION: This study confirms that mortality and morbidity are high following odontoid fractures. The mortality rate was significantly higher in patients with displaced fractures, confirming our hypothesis. The mortality rate was especially high when patients with displaced fractures could not undergo surgery because of anesthesia contraindications. Also, there was a high rate of respiratory complications after anterior screw fixation of displaced fractures. CONCLUSION: Given our findings, conservative treatment should be compared to surgical treatment for displaced fractures and the anterior approach should be compared to the posterior one for surgical cases. LEVEL OF EVIDENCE: IV.

O-arm-guided sacroiliac joint injection: New techniques with reflux test.

Diagnosis of degenerative sacroiliac pain syndrome is difficult. Sacroiliac injection confirms diagnosis by relieving pain. The present study aimed to describe a sacroiliac injection technique under O-arm guidance. Fifty-four patients, with a mean age of 58 years, presenting resistant sacroiliac pain syndrome after two 2D CT-guided injections received O-arm guided sacroiliac injection. Anesthetic reflux on joint lavage validated the technique. Clinical efficacy was assessed as pain relief on a simple numeric scale (positive if>70%). Reflux was observed in 92% of cases. Pain was relieved in 81%, with mean score reduced to 3.1 from 8.5. O-arm guided sacroiliac injection was reproducible and relieved sacroiliac pain after failure of 2D-guided injection, thus confirming the clinical diagnosis.

A Case Series Study of Odontoid Fracture in the Elderly: A Severe Fracture Occurring Most Frequently in Osteoporotic Subjects.

The WHO definition of osteoporosis excludes cervical fractures. Recent studies suggest that atraumatic odontoid fractures (OF) may be favored by osteoporosis but global bone status for osteoporosis diagnosis has not been described. We present a case series of patients >65 years old hospitalized for low-energy OF who had an evaluation of their bone status within 3 months after fracture, including clinical risk factors of osteoporosis, bone mineral density (BMD), vertebral fracture assessment (VFA) by dual X-ray absorptiometry, and laboratory tests. Osteoporosis was defined as a T-score ≤ -2.5 on at least one site, or a bone fragility fracture associated with a T-score ≤ -1 at one site. Thirty-three patients were hospitalized for OF, 30 of them as a consequence of a low-energy impact: 20 women and 10 men (mean age: 85 years). Eight patients died before bone evaluation, four refused, and six were lost to follow-up. Twelve patients were included: 11 women and one man (mean age: 83.8 years). Ten out of twelve patients fulfilled diagnostic criteria of osteoporosis, including eight with previous osteoporotic fractures (six severe fractures). Eight fulfilled specific treatment of osteoporosis criteria, but only two were treated. The mean follow-up period was 12.2 ± 4.1 months. Prior to OF occurrence, all lived at home and were independent; at the time of discharge, six went to a nursing home. At 3 months of follow-up (n = 10), one was dead and nine lived at home. At 12 months (n = 9), two were dead and seven lived at home. This study provides for the first time a classical evaluation of osteoporotic status for low-energy OF in the elderly and shows that it occurs in osteoporotic subjects. These preliminary results require larger-scale studies to determine whether OF could be considered as a severe osteoporotic fracture. © 2018 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

The 14 July 2016 terrorist attack in Nice: The experience of orthopaedic surgeons.

BACKGROUND: On 14 July 2016, a terrorist drove a truck through the crowd on the Promenade des Anglais in Nice, France, killing 87 people and injuring 458. The objective of this study was to evaluate the management strategy used to handle the osteo-articular injuries caused by this attack. HYPOTHESIS: The management strategy used ensured that open fractures were treated within 6hours. MATERIAL AND METHOD: This single-centre retrospective study included all victims of the attack admitted to the Pasteur 2 Hospital in Nice, France, for osteo-articular injuries, and treated between 14 and 31 July 2016. The following data were collected for each patient: age, sex, type of injury, Injury Severity Score (ISS), whether the damage control orthopaedics (DCO) or early total care (ETC) approach was followed, time from injurytotreatment, operative time, and surgical revisions. The primary outcome measure was the injury to treatment time for each lesion. RESULTS: Of the 182 patients admitted to the emergency department, 32 required admission for osteo-articular injuries, including 18 with severe injuries (ISS>15) and 11 with multiple fractures. Their injuries were of the type seen in traffic accidents. Of the 87 fractures, 45% involved the lower limbs and 25% were open fractures. Surgery was performed in 14 patients on the first night (14 to 15 July) and in 19 patients overall. The approach was DCO in 12 and ETC in 7 of these 19 patients. All lesions were managed within recommended time intervals, including the 21 open fractures and 2 closed femoral shaft fractures. DISCUSSION: Injury-to-surgery time complied with recommendations in all cases. In 25% of cases, ETC would have been feasible during the mass influx of patients without hospital capacity saturation. LEVEL OF EVIDENCE: IV, retrospective observational study.

The infraorbital artery: From descriptive anatomy to mucosal perforator flap design.

BACKGROUND: The terminal and perforating branches of the infraorbital artery (IOA) are poorly described. Its anatomical situation and mucosal component could provide an interesting donor site for mucosal reconstruction. The aims of the following study were to establish an anatomical description and to assess the feasibility of mucosal perforator flaps for eyelid and nasal reconstruction. METHODS: Twenty-three fresh cadaver hemifaces were studied in order to perform an IOA anatomical classification by recording the artery's characteristics, its course, number, type, and diameter of terminal branches. We also examined the feasibility of local flaps for facial reconstruction. RESULTS: We highlighted five different types of courses. All cadavers had at least one superior vestibular branch with a caliber of ≥0.4 mm. A pedicled flap arising from the vestibular branch was raised in all dissections. CONCLUSION: The vestibular perforator flap based on the IOA seems to be a reliable flap in reconstruction of mucosal defects.

Inferior Cubital Artery Perforator Flap for Soft-Tissue Coverage of the Elbow: Anatomical Study and Clinical Application.

BACKGROUND: Soft-tissue defects surrounding the elbow can be a challenging problem for the orthopaedic surgeon. Reliable reconstruction with use of muscular flaps or even perforator flaps derived from the surrounding vessels has been described. The inferior cubital artery (ICA) is an indirect septocutaneous perforator branch that most frequently arises from the lateral side of the radial artery. The purposes of the present study were to characterize the capillary cutaneous perforators of the ICA and to evaluate the potential of a local perforator flap procedure for soft-tissue coverage of the elbow. METHODS: Twenty fresh cadaveric forearms were dissected in order to describe the ICA anatomy, and in ten additional forearms the ICA was selectively injected with a red ink solution to detail the ICA vascular territory. For each artery, we recorded the site of origin, the diameter of the artery at its source, the course of the artery, and the number, type, and diameter of capillary cutaneous perforators. RESULTS: A total of seventy-eight ICA capillary perforators were analyzed from the twenty dissected forearms: forty-six were in-transit capillary perforators, nineteen were terminal capillary perforators, and thirteen were musculocutaneous capillary perforators. Of these seventy-eight perforators, sixteen (21%) had a caliber of <0.5 mm and sixty-two capillary perforators (79%) had a caliber of ≥0.5 mm. Ten ICAs were selectively injected, and the mean size of all stained skin areas was 30.9 ± 11.9 cm(2). A perforator pedicled flap was readily feasible for all dissections. We also describe the case of a patient with a medial soft-tissue defect of the elbow that was covered with a pedicled perforator flap based on an ICA. The patient had satisfactory healing at two months. CONCLUSIONS: The ICA flap is a reliable and useful flap for elbow soft-tissue reconstruction. CLINICAL RELEVANCE: The perforator flap procedure is a major advancement in reconstructive surgery. One potential application of the perforator flaps is the use of tissue adjacent to a defect as a perforator-based island flap. The use of this tissue allows for thinner flaps to be tailored for more accurate reconstruction. A flap that depends on a perforator branch of the radial artery called the inferior cubital artery seems to be an excellent solution for soft-tissue coverage of the elbow.

One-stage percutaneous treatment in a patient with pelvic and vertebral compression fractures.

An active 38-year-old patient presenting a vertebral compression fracture associated with a pelvic fracture was treated in one stage with CT-guided fixation of the sacrum and kyphoplasty. This treatment decreased the pain, restored the vertebral height, and enabled the patient to be ambulatory. The main advantage of this double approach was to shorten the hospital stay and the nonworking period.

Division of the right posterior attachments of the head of the pancreas with a linear stapler during pancreaticoduodenectomy: vascular and oncological considerations based on an anatomical cadaver-based study.

BACKGROUND: Section of the right posterior attachment (RPA) of the pancreatic head from the adventicia of the superior mesenteric artery (SMA) is the last step of pancreaticoduodenectomy. This procedure might be technically demanding, time consuming and potentially dangerous. A method using a stapler has been proposed to simplify this step of the pancreaticoduodenectomy. METHODS: To evaluate the potential consequences of RPA section using this new method, we used an experimental model of pancreaticoduodenectomy in 20 cadavers. After RPA stapling, the residual areolar tissue located between the staple line and SMA was removed (by sub adventicial dissection) and weighed. This allowed an evaluation of: (1) the theoretical risk of SMA injury and (2) the potential carcinological consequences of using stapling division, in comparison with the lymphadenectomy obtained with the conventional sub-adventicial dissection. RESULTS: A right hepatic artery was accidentaly injured in 10% of cases because of the lack of arterial dissection and arterial anatomy recognition. Forty-three percent of the RPA containing nerves and lymphatics remains in place. Using the stapling technique for RPA division theoretically increases the risk of micro or macroscopically positive margin after surgical resection. CONCLUSION: The result of this human cadaver-based dissection suggests that the use of the mechanical stapling device for final division of the RPA might increase the risk of SMA injury. The risk of vascular injury has been reported in surgical literature and is confirmed by this study. Such results (10% of accidentaly injury) may not be representative in leaving human patients, thanks to the use of a detectable palpable pulse of the SMA. The latter is important in avoiding vascular injury during RPA division. This study also shows that this new technique may increase the risk of incomplete tumor resection.

Modeling the pregnant woman in driving position.

Despite motor vehicle crashes being the leading cause of traumatic fetal morbidity, only a few researches have tried to study the automobile crashes on pregnant women. The possible negative effect of the restraint systems and the injuries mechanisms involved in car crashes with pregnant women are therefore still poorly understood. In this context, the aim of this study is to develop a numerical model of the whole human body with a gravid uterus, in order to investigate car crash scenarios and to evaluate alternative security systems to improve protection of both the woman and the fetus. A 3D reconstruction based on a set of MRI images led us to a good spatial representation of the pregnant woman in driving position. The anatomical precision will make progress possible in the field of traumatology of the pregnant woman.

A new method to approach exact hemoperitoneum volume in a splenic trauma model using ultrasonography.

In the trauma setting, the Focused Assessment for the Sonographic examination of the Trauma patient (FAST) accurately detects hemoperitoneum. Currently, only an approximate evaluation of the volume of free intraperitoneal fluid (FIPF) can be done by imaging modalities such as ultrasound (US). The aim of this study was to correlate the thickness of FIPF measured by US in different sites of the peritoneal cavity with the total volume of an experimental post-traumatic hemoperitoneum. An intra-abdominal collection with ongoing bleeding was simulated in eight cadavers with no previous abdominal surgery. Between 200 and 2000 ml of saline solution was instilled into the left hypochondrium of eight non-embalmed cadavers. During the instillation, FIPF thickness was measured every 200 ml by US in six different declivous sites of the peritoneal cavity. The volume of FIPF instilled could be mathematically correlated with fluid thickness in all the sites through the linear equation Y=aX+b, where Y is the volume of FIPF in milliliters, a is 33 (variability coefficient), X is the FIPF thickness in millimeters and b is 470 ml (minimum volume detectable by US). The best correlation between thickness and volume was obtained in the hepatorenal pouch (Morrison pouch). Evaluation of the impact of intraperitoneal hemorrhage on the hemodynamic state of spleen trauma patients is of paramount importance for the surgeon, who has to decide whether to perform a laparotomy for hemostasis or not, specially when intra- and extra-abdominal injuries conjointly exist. After clinical validation, this new method to calculate the exact volume of FIPF could be used in current clinical practice of abdominal trauma to assist in the decision-making regarding non-operative treatment of spleen trauma.