WALANT in hand surgery: Ischemic complications and their medicolegal implications in France: A systematic review of the literature and of French legal databases.

WALANT (Wide Awake Local Anesthesia No Tourniquet) presents a theoretical risk of digital ischemia due to the presence of epinephrine, associated to the local anesthetic. For this reason, in France, the market authorization prohibits the use of epinephrine in digital extremities. The main objective of the present study was to assess the risk of ischemic complications reported in literature, and then to analyze the medicolegal implications in France. A systematic literature review was performed by three independent readers, using the PubMed and Embase databases. Also, declarations of claims and legal proceedings between 2007 and 2020 in France were examined in the official national Légifrance and Doctrine databases. Eight of the 424 articles retrieved were selected. Only 3 cases of digital necrosis following local anesthesia with adrenalized lidocaine were reported. Adrenalized xylocaine may be considered in case of peripheral microcirculation disorder. From a medicolegal point of view, no complaints or medicolegal implications were associated with WALANT in France. It seems that the market authorization for adrenalized local anesthesia could be extended to use in the digital extremities. However, the lack of medical and legal data calls for caution. We therefore recommend the use of an institutional protocol specifying the cases of overdose and the patient's pathway, and training for practitioners wishing to use this technique.

"Snapping triceps": A rare and misleading condition - a clinical case report.

Snapping triceps corresponds to subluxation of the medial head of the triceps brachii over the medial epicondyle during active elbow flexion. It is a rare and misleading condition that is often associated with ulnar nerve instability. The latter can result in the snapping triceps being missed. Diagnosis requires a detailed clinical examination. Surgical treatment consists of anterior translocation of the nerve with an adipose flap to stabilize it and transfer of the distal attachment of the medial head of triceps brachii.

Subacromial temperature profile during bipolar radiofrequency use in shoulder arthroscopy. Comparison of Coblation® vs. VAPR®.

BACKGROUND: The use of bipolar electrodes for arthroscopic procedures carries a theoretical ex vivo risk of inducing burn injuries. Few studies have measured the in vivo temperatures produced by bipolar electrodes during arthroscopy, and their results are conflicting. The objective of this study was to evaluate the temperature profile within the subacromial space during shoulder arthroscopy with two different electrode systems. HYPOTHESIS: The primary hypothesis was that the two electrode systems produced similar temperature variations and peak temperatures. The secondary hypothesis was that neither electrode system produced irrigation-fluid temperatures above the tissue-damage threshold. MATERIAL AND METHODS: A comparative, prospective, single-centre, single-surgeon, single-blind study was conducted to compare the Coblation® system (Smith&Nephew, Andover, MA, USA) and the VAPR® system (DePuy Synthes Mitek Sports Medicine, Raynham, MA, USA) in 13 patients undergoing shoulder arthroscopy. A temperature probe inserted into the subacromial space was used to record temperatures at 10-second intervals for 60seconds during continuous radiofrequency application. RESULTS: Mean baseline temperature was 21.4±0.7°C with VAPR® and 23.0±2.2°C with Coblation®. No significant between-group differences were found during the first 40seconds. The mean peak temperature reached after 60seconds was 25.0±1.9°C with VAPR® and 27.9±2.8°C with Coblation® (P<0.05). DISCUSSION: Few studies have compared the in vivo temperatures produced during arthroscopy by different electrode systems. In vivo studies have established that temperature increases can cause tissue damage, particularly to chondrocytes, and that the irrigation flow rate plays a key role in lowering the in vivo temperatures. Our study showed a significant difference between the two electrode systems after 50seconds of use, with lower temperatures with the VAPR®. Nevertheless, neither system increased the irrigation-fluid temperatures above the tissue-damage threshold. Both systems can be used safely, provided the manufacturer instructions are followed and the irrigation system is effective. LEVEL OF EVIDENCE: II (prospective randomized trial).

Could the orthopaedic surgeon deployed in austere setting perform flaps on the leg?

The orthopaedic military surgeons deployed in operations are led to perform soft tissue coverage on the lower limb. The purpose of this study was to evaluate if flaps performed by surgeons' non-specialist in reconstructive surgery are associated with good outcome. All patients operated for a flap on the leg in French Forward Surgical Team deployed in theatre of operations between 2003 and 2013 were retrospectively reviewed. Forty-nine patients were included, for a total of 54 flaps' procedures. Indications were open fractures in 25 cases and osseous infections in 29 cases. No flap was performed on French soldiers. All the flaps were pedicle. Outcome was favourable for more than 90% of flaps with no statistical difference between muscular and fasciocutaneous flap and with regard to the indication. In conclusion, an orthopaedic surgeon deployed in austere setting with significant good outcome can perform reconstructive surgery with legs' flaps.

Limb reconstructive surgery in austere settings: use of flaps in French forward surgical facilities.

INTRODUCTION: Military surgeons deployed abroad must achieve soft tissue coverage under austere conditions. HYPOTHESIS: A non-specialized surgeon can achieve soft tissue coverage with good results. MATERIAL AND METHOD: This is a retrospective study of all patients who underwent soft tissue coverage in French forward surgical units between 2003 and 2013. RESULTS: In all, 81 flaps were constructed. Open fractures (39%) were the leading indication, followed by osseous infections (35%). Most flaps were for legs (70%) and hands (25%). Only pedicle flaps were used. The success rate was 91%. DISCUSSION: Flaps can be constructed by orthopedic surgeons who are not specialized in reconstructive surgery, in austere settings and with good results. This procedure must be part of a global strategy of limb reconstruction, especially in cases of bone and joint infection. Pedicle flaps, especially muscular, appear more reliable and are to be preferred. The training of the surgeons deployed abroad must include flap surgery.

When the tendon autograft is dropped accidently on the floor: A study about bacterial contamination and antiseptic efficacy.

BACKGROUND: Inadvertent contamination of the autograft can occur during anterior cruciate ligament (ACL) reconstruction if the autograft is dropped on the floor during surgery. A study was undertaken to determine the incidence of contamination when a graft is dropped on the operating room floor and the efficacy of antimicrobial solutions to decontaminate it. METHODS: Samples from 25 patients undergoing ACL reconstruction with a hamstring tendon were sectioned and dropped onto the floor. Cultures were taken after immersion in antiseptic solutions (a chlorhexidine gluconate solution (group 1), a povidone-iodine solution (group 2), and a sodium hypochlorite solution (group 3)). A fourth piece (group 0) was cultured without being exposed to any solution. Cultures of a floor swab were taken at the same time. RESULTS: The floor swab cultures were positive in 96% of cases. The rate of contamination was 40% in group 0, 8% in group 1, 4% in group 2, and 16% in group 3. There was a significant difference between groups 1 and 2 and group 0 (p<0.05) but not between groups 3 and 0. CONCLUSIONS: Immersing a graft dropped on the floor during surgery in a chlorhexidine gluconate solution or povidone-iodine solution significantly reduces contamination of the graft. Soaking of the hamstring autograft in one of these solutions is recommended in the case of inadvertent contamination. CLINICAL RELEVANCE: Laboratory investigation (level 2).

Surgical management of Syria's war casualties: experience from a French surgical team deployed in the Zaatari refugee camp (Jordan).

PURPOSE: In August 2012, the Zaatari refugee camp was opened in Jordan under the auspices of the United Nations High Commissioner for Refugees. France deployed there a surgical facility to treat victims of war trauma. METHODS: After a phase of intensive care and resuscitation, surgical management meeting the current standards of war surgery was conducted. Then, patients were transferred to a Jordanian civilian hospital or stayed in the Zaatari camp. A retrospective analysis of patient data was performed. RESULTS: From January to March 2013, 95 patients were managed: 85% of patients were male with a median age of 27 years (4-65); 5% of patients were <18 years of age. All patients were Syrian, civilian or members of the "Free Syrian Army." Penetrating trauma accounted for 95% of lesions. A total of 105 surgeries were performed, including: 33 external fixators, 8 laparotomies, 8 nerve repairs, 6 cover flaps, 4 direct arterial repairs, 2 reversed saphenous vein bypass grafts, and 1 amputation. The median length of stay on the wards was 3.71 days; 43% of patients were transferred to Jordanian civilian hospitals. CONCLUSIONS: The presence at the Zaatari camp of a surgical facility, which is experienced and specialized in war surgery, is essential, as long as battles are ongoing. Many victims will later require long-term surgical care for the management of the sequelae associated with these traumas.

[Medical and economic impact of a haemostatic sealant on the rate of transfusion after total knee arthroplasty]. / Impact médicoéconomique d'une colle hemostatique sur le taux de transfusion après prothèse totale de genou.

OBJECTIVES: Blood loss reduction in total knee arthroplasty (TKA) contributes to the prevention of morbidity and mortality and in the management of health care costs. Fibrin haemostatic sealant have controversial effectiveness in reducing postoperative blood loss and transfusion requirements. Our study evaluated the medical and economic benefits of this treatment with the assumption that it decreases the frequency of blood transfusion after TKA. METHODS AND PATIENTS: Our single-center and randomized study included 60 patients pose unilateral primary TKA for osteoarthritis. Distribution was done in 2 groups of 30 patients each. Group 1 patients treated with a dose of 5 mL Evicel®, compared to untreated group 2. Were collected the number of patients transfused. The treatment cost was compared to the sealant cost. RESULTS: Results are not statistically significant. Two patients were transfused in group 1 and 3 in group 2 (P=0.64). The treatment cost for 30 patients is 13,500 €, for a savings of cells packed at 187 €, an additional cost of 13,313 € in group 1. CONCLUSION: The use of fibrin haemostatic sealant in TKA did not induce a significant difference in terms of blood or transfusion savings, with a significant cost. We do not recommend its routine use in TKA.

Outcomes of talar dome osteochondral defect repair using osteocartilaginous autografts: 37 cases of Mosaicplasty®.

BACKGROUND: The indications of osteochondral autograft implantation using the Mosaicplasty(®) technique were only recently extended to osteochondral lesions of the talus (OLT), a site for which no medium- or long-term outcome data are available. Our objective here was to evaluate medium-term outcomes in case-series of patients who underwent Mosaicplasty(®) for OLT repair. HYPOTHESIS: Mosaicplasty(®) provides good medium-term outcomes with low morbidity when used for OLT repair. PATIENTS ET METHODS: We retrospectively reviewed cases of Mosaicplasty(®) for OLT repair, performed in combination with malleolar osteotomy on the side of the OLT, at either of two centres, between 1997 and 2013. Pre-operative clinical data were collected from the medical records and all patients were re-evaluated. We studied 37 patients with a mean age of 33 years. RESULTS: Mean follow-up at re-evaluation was 76 months. Mean AOFAS score at re-evaluation was 83 (range, 9-100). A work-related cause to the OLT was associated with significantly poorer outcomes (P=0.01). AOFAS values were significantly better in patients whose OLT size was 0.5 to 1cm(2). The Ogilvie-Harris score at last follow-up was good or excellent in 78% of patients. No patient experienced morbidity related to the malleolar osteotomy. Persistent patellar syndrome was noted in 6 patients. DISCUSSION: In our case-series, Mosaicplasty(®) for OLT repair provided good medium-term outcomes in 78% of patients. Nevertheless, the donor-site morbidity should be borne in mind. Mosaicplasty(®) deserves to be viewed as a reference standard method for OLT repair. LEVEL OF EVIDENCE: IV, retrospective study.

Failed subacromial decompression. Risk factors.

BACKGROUND: Arthroscopic subacromial decompression (acromioplasty) is widely held to be effective, although pain may persist after the procedure. The objective of this study was to evaluate the proportion of patients with residual pain (i.e., the failure rate) after isolated subacromial decompression and to look for predictors of failure. MATERIAL AND METHOD: We conducted a retrospective multicentre study of 108 patients managed with isolated arthroscopic subacromial decompression between 2007 and 2011, for any reason. We excluded patients in whom surgical procedures on the rotator cuff tendons were performed concomitantly. Data were collected from the medical records, a telephone questionnaire, and radiographs obtained before surgery and at last follow-up. Failure was defined as persistent pain (visual analogue scale score>3) more than 6 months after surgery and at last follow-up. RESULTS: The failure rate was 29% (31/108). Two factors significantly predicted failure, namely, receiving workers' compensation benefits for the shoulder condition and co-planing. Heterogeneous calcific tendinopathy and deep partial-thickness rotator cuff tears were also associated with poorer outcomes, but the effect was not statistically significant. DISCUSSION: Co-planing may predict failure of subacromial decompression, although whether this effect is due to an insufficient degree of co-planing or to the technique itself is unclear. Nevertheless, in patients with symptoms from the acromio-clavicular joint, acromio-clavicular resection is probably the best option. Receiving workers' compensation benefits was also associated with treatment failure, as a result of well-known parameters related to the social welfare system. CONCLUSION: Isolated arthroscopic subacromial decompression is effective in 70% of cases. We recommend the utmost caution if co-planing is considered and/or the patient receives workers' compensation benefits for the shoulder condition, as these two factors are associated with a significant increase in the failure rate. LEVEL OF EVIDENCE: IV (retrospective study).

French surgical experience in the role 3 medical treatment facility of KaIA (Kabul International Airport, Afghanistan): the place of the orthopedic surgery.

INTRODUCTION: In 2009, the French took command of the Medical Hospital (MH) or Role 3 Hospital at KaIA (Kabul International Airport) within the framework of its role in the military mission Operation Pamir in Afghanistan. The goal of this study was to analyze the volume of orthopedic surgical activity for the last four years, to identify its specificities and to improve training of military orthopedic surgeons. HYPOTHESIS: Orthopedic surgery is the most important activity in the field and surgeons must adapt to situations and injuries that are different from those encountered in France. PATIENTS AND METHODS: All patients operated on between July 2009 and June 2013 were prospectively included in an electronic database. The analysis included the number of surgical acts and patients, the types of injuries and the surgical procedures. RESULTS: Forty-three percent (n=1875) of 4318 procedures involved orthopedic surgery. Half of these were emergencies. French military personnel represented 17% of the patients, local civilians 47% and children 17%. Half of the procedures involved the soft tissues, 20% were for bone fixation and 10% for surgery of the hand. The rate of amputation was 6%. The diversity of the surgical acts was high ranging from emergency surgery to surgical reconstruction. DISCUSSION: The activity of this Role 3 facility is comparable to that of other Role 3 facilities in Afghanistan, with an important percentage of acts involving medical assistance to the local population and scheduled surgeries as well as primary and/or secondary management of the wounded. The diversity of surgical acts confirms the challenge of training military orthopedic surgeons within the context of the hyperspecialization of the civilian sector. Specific training has been organized in France by the École du Val de Grâce. Specific continuing education is also necessary. LEVEL OF EVIDENCE: IV (retrospective review).

Wartime upper extremity injuries: experience from the Kabul International Airport combat support hospital.

Few epidemiologic studies have been published about the surgical management of wartime upper extremity injuries (UEIs). The purpose of the present report was to analyze upper extremity combat-related injuries (CRIs) and non-combat related injuries (NCRIs) treated in the Kabul International Airport Combat Support Hospital. A retrospective study was conducted using the French surgical database OpEX (French military health service) from June 2009 to January 2013. During this period, 491 patients with a mean age of 28.7 ± 13 years were operated on because of an UEI. Among them, 244 (49.7%) sustained CRIs and 247 (50.3%) sustained NCRIs. A total number of 558 UEIs were analyzed. Multiple UEIs and associated injuries were significantly more common in the CRIs group. Debridement was the most common procedure in both groups. External fixator application, delayed primary closure and flap coverage were predominant in the CRIs group, as well as internal fracture fixation and tendon repair in the NCRIs group. The overall number of surgical episodes was significantly higher in the CRIs group. Due to the high frequency of UEIs in the theatres of operations, deployed orthopedic surgeons should be trained in basic hand surgery. Although the principles of CRIs treatment are well established, management of hand NCRIs remains controversial in this setting.

Faecal carriage of extended-spectrum ß-lactamase-producing enterobacteria among soldiers at admission in a French military hospital after aeromedical evacuation from overseas.

The aim of this study was to assess the faecal carriage of carbapenemase-producing enterobacteria (CPE) and extended-spectrum ß-lactamase (ESBL)-producing enterobacteria among soldiers at admission in a French military hospital after aeromedical evacuation from overseas. During a period of 1 year, 83 rectal swabs collected in French soldiers at admission were screened for multidrug-resistant enterobacteria with a chromogenic medium. ESBL detection was performed with the double-disc synergy test in the absence or presence of cloxacillin. The genotypic characterisation of resistance mechanisms, sequence typing and phylotyping was performed by polymerase chain reaction (PCR) and sequencing with bacterial DNA extracted from isolates. No CPE was detected. Eleven ESBL Escherichia coli isolates belonging to four phylogenetic groups were detected, including ten CTX-M-15 and one CTX-M-14. The overall gut colonisation with ESBL-producing bacteria (13.25 %) was 6-fold higher than that reported in soldiers in the suburbs of Paris in 2009. ESBL faecal carriage was particularly high (34.48 %) in soldiers repatriated from Afghanistan (risk ratio = 18.62; p = 0.0001). This study highlights the importance of systematic additional contact precautions and CPE/ESBL screening in soldiers repatriated from overseas in French hospitals.

The posterior malleolar fracture: a parachute injury not to be overlooked.

INTRODUCTION: Isolated posterior tibial malleolar fracture, which concerns parachutists in particular, is rare and often overlooked. The present study sought to identify clinical and paraclinical factors able to improve diagnosis and treatment. HYPOTHESIS: Marginal posterior malleolar fracture is under-diagnosed due to lack of awareness and difficulty of diagnosis. Delayed diagnosis may impair functional prognosis. MATERIAL AND METHOD: A multicenter retrospective study included 12 cases of isolated marginal posterior malleolar fracture in military parachutists between 2006 and 2011. Clinical and paraclinical data were collected from medical files and a questionnaire administered in consultation or by telephone. RESULTS: Diagnosis was initially overlooked in 75% of cases due to non-specific clinical presentation and the low sensitivity of plain radiographs. Diagnostic delay impaired functional outcome. DISCUSSION: Symptomatology, other than medial retromalleolar pain, is misleading. The Ottawa Ankle Rules should not be used in this particular form of trauma. X-ray should include a lateral view in 50° external rotation. CT provides a useful complement. Delayed diagnosis puts the patient at risk of impaired functional prognosis. LEVEL OF EVIDENCE: IV (retrospective study).

Surgical management of combat-related upper extremity injuries.

This review presents the current surgical management of combat-related upper extremity injuries during the acute phase. The strategy consists of saving the life, saving the limb and retaining function. Surgical tactics are based on damage control orthopaedics techniques of haemorrhage control, wound debridement, and temporary bone stabilization prior to evacuation out of the combat zone. Features of the definitive management of local casualties in battlefield medical facilities are also discussed. In this situation, reconstructive procedures have to take into account the limited resources and operational constraints.

Interest of an intraoperative limb-length and offset measurement device in total hip arthroplasty.

INTRODUCTION: Total hip arthroplasty (THA) seeks to restore a stable, mobile and pain-free joint. This requires good implant positioning and peroperative restoration of limb-length and femoral offset. HYPOTHESIS: A mechanical measurement device (length and offset optimization device [LOOD]) fixed to the pelvis can optimize lower-limb length and offset control during THA performed on a posterolateral approach. PATIENTS AND METHODS: Two prospective THA series were compared: 32 using the LOOD and 26 without. Patients with more than 5mm preoperative limb-length discrepancy were excluded. The intraoperative target was to restore individual anatomy. Radiographic analysis was based on pre- and postoperative AP pelvic weight-bearing views in upright posture, feet aligned, with comparison to peroperative LOOD data. RESULTS: Mean deviation from target length (i.e., pre- to postoperative length differential) was 2.31 mm (range, 0.04-10.6mm) in patients operated on using the LOOD versus 6.96 mm (0.01-178 mm) without LOOD (P=0.0013). Mean deviation from target offset was 3.96 (0.45-13.50) mm with LOOD versus 10.16 (0.93-28.81) without (P=0.0199). There was no significant difference between operative and radiographic measurements of length deviation using LOOD (P=0.4); those for offset, however, differed significantly (P=0.02). DISCUSSION: The LOOD guides control of limb-length and offset during THA on a posterolateral approach. Reliability seems to be better for limb-length than for offset. It is a simple and undemanding means of controlling limb-length and offset during THA. LEVEL OF EVIDENCE: III, prospective case-control study.