Hand wounds: An analysis of topography and related damage to underlying structures.

INTRODUCTION: Hand wounds account for 35 to 51% of hand traumas. Damage to underlying anatomical structures depends on the location of the wound. The objective of this study is to describe the topographic distribution of hand wounds allowing for subsequent evaluation of the link between affected surface area and underlying lesion. METHODS: We retrospectively reviewed the medical records of 1058 patients with a total of 1319 wounds over a period of 2 years. Wound location was described according to the cutaneous projection of IFSSH zones for flexors and extensors. Any associated deep lesions were evaluated. Topographical distribution was modeled graphically using a heat-map. We compared the proportion of underlying lesions between each cutaneous zone. Sub-group analysis for lesions' rate regarding zone groups were performed. RESULTS: 58.9% of wounds were located on the palmar surface and 41.1% on the dorsal surface. 71% of wounds affected only the digits. The index finger was the most affected. The most damaged region was zone 2 for palmar wounds and zone 3 for dorsal wounds. 45.5% of wounds resulted in injury to a significant underlying anatomical structure. This frequency was 36.4% and 58.5% for palmar and dorsal wounds respectively. More than 50% of wounds in palmar zone 5 and dorsal zones 1, 3, 5, 6 and 7 presented at least one lesion. A lesion of major structure was more frequently found in palmar zone 5 (p <0.001). Dorsally, no zone predominated. Subgroup analysis for dorsal wounds revealed that wounds overlying joints had more major lesions including more tendons injuries and more articular violations with zone 3 presenting a rate of 68%. CONCLUSION: We provided the first graphical representation for the topographical distribution of hand wounds. Dorsal wounds have a higher association with injury to underlying structures. These results generally support surgical exploration of all hand wounds regardless of their location. LEVEL OF EVIDENCE: IV Study type: Epidemiological study.

Os acromiale: a review of its incidence, pathophysiology, and clinical management.

An os acromiale occurs when any of the primary ossification centres of the acromion fail to fuse with the basi-acromion. It is present in approximately 8% of individuals, and whilst the majority of these individuals are unaffected it can cause significant pain and disability. It can impact seemingly unrelated surgical intervention in the region such as subacromial decompression and reverse shoulder arthroplasty. A painful os acromiale can be both a diagnostic challenge, and difficult to manage. There remain a wide variety of surgical practices with variable outcomes achieved. We present an evidence-based discussion of the surgical techniques described to date in the literature, alongside a comprehensive review of the incidence and pathophysiology of os acromiale.This review was written after a comprehensive analysis of the literature to date relating to os acromiale. Particular focus was given to material examining surgical management techniques, and the condition's incidence across different population groups.Open reduction and internal fixation using cannulated screws, or tension band wiring have superior outcomes in the literature in the treatment of symptomatic os acromiale. There may be a biomechanical advantage of combining the two techniques. Preservation of large anterior deltoid attachment is necessary, with consideration being given to the local blood supply. There is likely no additional benefit from iliac crest vs local bone grafting. Research in this area remains of a low evidence level with small samples sizes. Appropriately powered clinical research of a higher-level evidence methodology is needed in order to differentiate further in the choice of surgical intervention. Cite this article: EFORT Open Rev 2019;4:525-532. DOI: 10.1302/2058-5241.4.180100.

Safety of raltegravir-based antiretroviral therapy in HIV-infected patients receiving multi-kinase inhibitors.

Background The risk of pharmacokinetic interaction is important in HIV-infected cancer patients receiving concomitantly highly active antiretroviral therapy (HAART) and anti-cancer systemic treatments. We aimed to evaluate the safety profile of raltegravir-based HAART in cancer patients receiving multi-kinase inhibitors (MKIs). Patients and Methods We conducted a retrospective medical record review of adult, HIV-infected cancer patients treated in our institutions from January 2010 to December 2015. Patients eligible for the present analysis were those receiving a raltegravir-based HAART at the time of the initiation of a MKI for the treatment of advanced solid tumors. Treatment-related toxicity, virological outcomes and pharmacokinetic profile of MKIs were examined. Results Twelve patients (7 males, median age 55 years) were identified. Seven had sarcoma/GIST, 3 had hepatocellular carcinoma, one had pancreatic neuroendocrine tumor, and one had NSCLC. Patients received the following MKIs: imatinib (n = 3), sorafenib (n = 3), pazopanib (n = 3), sunitinib (n = 2) and erlotinib (n = 1). The mean CD4+ count at baseline was 929 cells/mm3, and 860 cells/mm3 after completion of MKI treatment. In all patients, HIV viral loads remained below the limit of detection (40 copies/ mm3) during the whole MKI treatment. No virological failure occurred. No unexpected or serious adverse event related either to raltegravir-based HAART or to MKIs was observed. The trough plasma concentrations of MKIs were assessed in 8 patients, and were found normal in all but one case (not related to raltegravir-based HAART). Conclusions The present data represent the first documentation of the concomitant use of raltegravir-containing HAART and MKIs in HIV-infected adult patients with advanced non-AIDS defining malignancies, with a reassuring safety profile.

Terrorist attacks in Paris: Surgical trauma experience in a referral center.

BACKGROUND: On November 13th, 2015, terrorist bomb explosions and gunshots occurred in Paris, France, with 129 people immediately killed, and more than 300 being injured. This article describes the staff organization, surgical management, and patterns of injuries in casualties who were referred to the Teaching European Hospital Georges Pompidou. METHODS: This study is a retrospective analysis of the pre-hospital response and the in-hospital response in our referral trauma center. Data for patient flow, resource use, patterns of injuries and outcomes were obtained by the review of electronic hospital records. RESULTS: Forty-one patients were referred to our center, and 22 requiring surgery were hospitalized for>24h. From November 14th at 0:41 A.M. to November 15th at 1:10 A.M., 23 surgical interventions were performed on 22 casualties. Gunshot injuries and/or shrapnel wounds were found in 45%, fractures in 45%, head trauma in 4.5%, and abdominal injuries in 14%. Soft-tissue and musculoskeletal injuries predominated in 77% of cases, peripheral nerve injury was identified in 30%. The mortality rate was 0% at last follow up. CONCLUSION: Rapid staff and logistical response, immediate access to operating rooms, and multidisciplinary surgical care delivery led to excellent short-term outcomes, with no in-hospital death and only one patient being still hospitalized 45days after the initial event.

New dynamic three-dimensional MRI technique for shoulder kinematic analysis.

PURPOSE: To establish a new imaging technique using dynamic MRI three-dimensional (3D) volumetric acquisition in real-time, on six normal shoulders for the analysis of the 3D shoulder kinematics during continuous motion. MATERIALS AND METHODS: At first, a standard static acquisition was performed. Then, fast images were obtained with a multi-slice 3D balanced gradient echo sequence to get a real time series during the initial phase of shoulder abduction. Subsequently, the images were reconstructed; registered and the translational patterns of the humeral head relative to the glenoid and the size of the subacromial space were calculated. Additionally, the intraobserver reproducibility was tested. RESULTS: The maximal abduction was on average 43° (30° to 60°) and the mean width of the subacromial space was 7.7 mm (SD: ±1.2 mm). Difference between extreme values and average values was low, respectively 2.5 mm on X-axis, 2 mm on Y-axis, 1.4 mm for the width of the subacromial space and 1.2° for the measure of the glenohumeral abduction. CONCLUSION: This study reported a dynamic MRI protocol for the monitoring of shoulder 3D kinematics during continuous movement. The results suggest that there is no superior shift of the humeral head during the first phase of abduction.

Accuracy of glenoid component placement in total shoulder arthroplasty and its effect on clinical and radiological outcome in a retrospective, longitudinal, monocentric open study.

BACKGROUND: The success of Total Shoulder Arthroplasty (TSA) is believed to depend on the restoration of the natural anatomy of the joint and a key development has been the introduction of modular humeral components to more accurately restore the patient's anatomy. However, there are no peer-reviewed studies that have reported the degree of glenoid component mal-position achieved in clinical practice and the clinical outcome of such mal-position. The main purpose of this study was to assess the accuracy of glenoid implant positioning during TSA and to relate it to the radiological (occurrence of radiolucent lines and osteolysis on CT) and clinical outcomes. METHODS: 68 TSAs were assessed with a mean follow-up of 38+/-27 months. The clinical evaluation consisted of measuring the mobility as well as of the Constant Score. The radiological evaluation was performed on CT-scans in which metal artefacts had been eliminated. From the CT-scans radiolucent lines and osteolysis were assessed. The positions of the glenoid and humeral components were also measured from the CT scans. RESULTS: Four position glenoid component parameters were calculated The posterior version (6°±12°; mean ± SD), the superior tilt (12°±17°), the rotation of the implant relative to the scapular plane (3°±14°) and the off-set distance of the centre of the glenoid implant from the scapular plane (6±4 mm). An inferiorly inclined implant was found to be associated with higher levels of radiolucent lines while retroversion and non-neutral rotation were associated with a reduced range of motion. CONCLUSION: this study demonstrates that glenoid implants of anatomic TSA are poorly positioned and that this malposition has a direct effect on the clinical and radiological outcome. Thus, further developments in glenoid implantation techniques are required to enable the surgeon to achieve a desired implant position and outcome.

Prognostic scoring systems for spinal metastases in the era of anti-VEGF therapies.

STUDY DESIGN: Spine Update on prognostic scoring systems for spinal metastases in the era of anti-vascular endothelial growth factor (VEGF) therapies. OBJECTIVE: To review and discuss the strengths and weaknesses of available scoring systems since the introduction of molecular targeted anticancer agents. SUMMARY OF BACKGROUND DATA: Molecular targeted anticancer agents have dramatically improved survival of patients in various cancers, including renal cancer. METHODS: Using prognostic scoring systems for spinal metastases and recent survival data of patients with cancers treated with anti-VEGF agents, a review was undertaken, evaluating the strengths and weaknesses of available prognostic scoring systems designed in the 1990s and early 2000s among patients treated with recent agents (available from 2005). RESULTS: All available prognostic scoring systems for spinal metastases include the primary tumor as a key variable. The estimation of life expectancy with these systems is inaccurate in view of recent survival data, as illustrated in renal cancer. The underestimation of life expectancy and subsequent inadequate treatment of spinal metastases may lead to dramatic alteration of the quality of life. CONCLUSION: The assessment of the available scores in recent cohorts of patients is mandatory to test their current validity and evidence the need for aggressive surgical management. New scoring systems taking into account the gain in survival induced by recent anticancer agents will likely be warranted in a close future.

Measurement of femoral head penetration in polyethylene using a 3-dimensional CT-scan technique.

BACKGROUND: Current techniques for measuring in vivo polyethylene wear suffer from a range of problems, resulting in an unacceptable lack of repeatability and/or insufficient accuracy when they are used to measure the low wear rates associated with new, highly crosslinked polyethylene. We describe an improved CT method for measurement of 3D femoral head penetration in PE acetabular cups that has sufficient accuracy and repeatability to allow assessment of the wear potential of modern implants. METHOD: The accuracy and repeatability of the CT-scan method was determined by blindly repeating measurements on a precisely calibrated 28-mm prosthetic head and by comparing them with direct metrological measurements on 10 acetabular specimens with in vitro wear from machining, and on 8 explanted acetabular specimens with in vivo wear. RESULTS: The intra- and interobserver errors in femoral head diameter were 0.036 mm (SD 0.044) and 0.050 mm (SD 0.022), respectively. CT estimated femoral head penetration in both all-poly and metal-backed acetabular components with accuracy ranging from 0.009 to 0.245 mm (mean 0.080; SD 0.067). INTERPRETATION: We found that the CT method is rapid, is accurate, and has repeatability and ease of availability. Using a slice thickness of 0.0625 mm, this method can detect wear­and also the threshold for the wear rate that causes osteolysis­much earlier than previous methods.

Solubility of CaHPO4 · 2H2O in the System Ca(OH)2-H3PO4-H2O at 5, 15, 25, and 37.5 °C.

Solubility isotherms for CaHPO4 · 2H2O, dicalcium phosphate dihydrate, DCPD, in the ternary system Ca(OH)2 - H3PO4 - H2O were determined at 5, 15, 25, and 37.5 °C in the pH range 3.5 - 7; the relative positions of the isotherms indicate that DCPD has a negative thermal coefficient of solubility. The solubility product, K s , of DCPD and the stability constants K x and K y for the ion pairs [ CaHPO 4 0 ] and [ CaH 2 PO 4 + ] , respectively, were obtained as functions of temperature by the use of a generalized least squares procedure subject to three condition functions - constancy of the solubility product, electrical neutrality in the solution, and congruent dissolution of the solid. The equations obtained are ln K s = - 8403 .5 / T + 41 . 863 - 0 . 09678 T ​ln K x = - 51090 / T - 341.14 + 0 . 5880 T ​ln K y = - 19373 / T - 122.81 + 0 . 1994 T The existence of a maximum in K s in the neighborhood of 25 °C is plausible on the basis of available thermodynamic data for DCPD. Thermodynamic functions are reported for the solution of DCPD and for the association of the ion pairs.

Solubility of CaHPO4 · 2H2O and Formation of Ion Pairs in the System Ca(OH)2- H3PO4 - H2O at 37.5 °C.

The solubility isotherm for CaHPO4 · 2H2O (DCPD) in the three-component system Ca(OH)2 - H3PO4 - H2O was determined in the pH range 3.5 to 6.8 by leaching a thermostated column of DCPD with dilute phosphoric acid solutions. In confirmatory experiments, equilibrium was approached both from super- and under-saturation by shaking DCPD with appropriate solutions. The calculated ionic activity product (Ca++) × ( HPO 4 = ), appeared to be a parabolic function of pH with a minimum near pH 5.0. The pH dependence of the ionic product could be accounted for by considering the ion pairs [CaHPO4]° and [CaH2PO4]+ as semi-empirical parameters. Under the condition of saturation with respect to DCPD, the activity of the pair [CaHPO4]° must be a constant. The activity of the species [CaH2PO4]+ was shown to vary directly with hydrogen ion activity. The activities of the two ion pairs were adjusted to give a set of pH-independent ionic activity products with a mean of 2.19±0.011 × 10-7. The stability constants for [CaHPO4]° and [CaH2PO4]+ are 5.88±0.031 × 102 and 7.49 ±0.039, respectively. Experiments were conducted to study the hydrolysis of DCPD to more basic calcium phosphates and the kinetics of these transformations is discussed. The significance of the ion pairs in human serum is considered.