Severe Vertex Epidural Hematoma in a Child: A Case Report of a Management without Expert Neurosurgical Care

Vertex epidural hematomas (VEDHs) are an uncommon situation and difficulties may be encountered in their diagnosis and management. This is more complicated when the surgical management has to be performed by general surgeons, not specialized in neurosurgery, in a remote location. It was in this context that we were brought to care in charge a 2-year-old boy who required a neurosurgical emergency rescue for a severe VEDH in Djibouti. Through the description of this case, we want to emphasize the value of developing a network of teleconsultation for the benefit of remote and isolated locations and learning basic techniques of emergency neurosurgery

LES PLAIES DU COEUR ET DES GROS VAISSEAUX (A PROPOS D'UNE SERIE DE 18 CAS ET REVUE DE LA LITTERATURE)

LYON1-BU Santé (693882101) / SudocPARIS-BIUM (751062103) / SudocPARIS-Bib. Serv.Santé Armées (751055204) / SudocSudocFranceF

Intérêt de l'analyse de l'équilibre postural et du shéma de marche dans l'évaluation postopératoire après ligamentoplastie du LCA (étude préliminaire)

Il n'y a pas à l'heure actuelle de consensus sur les meilleurs examens à réaliser pour analyser les résultats d'une ligamentoplastie du ligament croisé antérieur (LCA), cohérents avec les résultats fonctionnels retrouvés et reproductibles.Le but de ce travail était d'essayer de définir un protocole idéal de surveillance de routine après ligamentoplastie du LCA en évaluant l'intérêt de l'analyse du contrôle postural et du schéma de marche ainsi que d'étudier la faisabilité d'une étude prospective. Nous avons revus dix-huit patients opérés d'une ligamentoplastie du LCA aux tendons ischiojambiers, avec mesure de la laximétrie (KNEELAX 3 ), de la force musculaire des quadriceps et ischio-jambiers (BIODEX SYSTEM 3 ), analyse du contrôle postural (posturométrie statique et dynamique, appareil SATEL ) et du schéma de marche (analyse 3D sur tapis de marche, appareil KNEE-KG ). Parallèlement, dix-huit sujets témoins ont bénéficié de la même évaluation. A un recul moyen de 11 mois postopératoires, avec un score IKDC moyen de 86, nous n'avons pas retrouvé de différence significative en termes de laxité entre les deux groupes. Il y avait par contre une légère altération de la récupération de la force musculaire à vitesse lente ainsi qu'une discrète altération du contrôle postural et du schéma de marche. La plupart des coefficients de corrélation n'étaient pas significatifs. Du fait des nombreux biais de notre étude, nos résultats n'étaient pas interprétables en l'état mais nous ont permis de guider notre revue de la littérature. La réalisation de l'étude statistique était une nécessité au vu de notre objectif secondaire. Nous proposons comme schéma de surveillance de routine une analyse préopératoire, puis postopératoire à 3, 6 et 12 mois de la laximétrie, de la force musculaire et du contrôle postural Nous ne recommandons pas l'analyse du schéma de marche par KNEE-KG car ce matériel s'est avéré difficile à mettre en place et n'apportant pas les résultats espérés. Une future étude prospective, contrôlée, devrait tenir compte des biais que nous avons essuyés et mettre l'accent sur la sélection de la population d'étude, être réalisée en simple aveugle et tenir compte du schéma de surveillance que nous avons proposé en réduisant le nombre de critères de jugementLYON1-BU Santé (693882101) / SudocPARIS-Bib. Serv.Santé Armées (751055204) / SudocSudocFranceF

Anterior cruciate ligament reconstruction with short hamstring grafts: the choice of femoral fixation device matters in controlling overall lengthening

Purpose: The purpose was to conduct an independent biomechanical study comparing the main types of femoral fixation adapted to short hamstring grafts in anterior cruciate ligament (ACL) reconstruction surgery and to validate their performance.Methods: The ACLip® Femoral, ToggleLoc™ Ziploop (TLZ), and Tape Locking Screw (TLS®) implants were tested in tension in the following three different configurations: implant alone, implant fixed on the femur without graft, and implant fixed on the femur with graft. Grafts alone were also tested. The femurs and the 4-strand semi-tendinosus grafts were derived from porcine and human models, respectively. Each set-up was subjected to the same protocol of creep (50 N for 30 s), cycling (1000 cycles between 50 and 250 N, 1 Hz), and load to failure (50 mm/min).Results: A total of 93 tests were performed (30 ACLip®, 30 TLZ, 20 TLS®, and 13 ST4 alone). For the implants tested with femur and graft, the mean ± standard deviation (SD) overall elongation at 250 N after cycling was 5.2 ± 0.2 mm, 8.4 ± 2.1 mm, and 5.3 ± 0.8 mm, the mean ± SD ultimate load to failure was 736 ± 116 N, 830 ± 204 N, and 640 ± 242 N, and the mean ± SD stiffness at the 1000th cycle was 185 ± 15 N/mm, 172 ± 19 N/mm, and 178 ± 21 N/mm for ACLip®, ToggleLoc™, and TLS® devices, respectively. There was no significant difference between the implants except for post-cycling elongation between TLZ and the other two implants (p < 0.05).Conclusion: The choice of femoral fixation device plays a decisive role in controlling the overall lengthening of an ACL reconstruction using a short hamstring graft. All implants validated the specifications in terms of ultimate load to failure, the TLS® system had, however, a low performance limit. ToggleLoc™ with adjustable loop should no longer be used on the femur side; instead the other types of fixation should be used to improve the overall elongation control

Risk factors for complications after primary intramedullary nailing to treat tibial shaft fractures: A cohort study of 184 consecutive patients

BACKGROUND: Intramedullary nailing is the standard of care for tibial shaft fractures. The risk factors for infectious and/or mechanical complications, notably non-union, remain incompletely understood. The objective of this study was to evaluate risk factors for complications, notably non-union. HYPOTHESIS: Active smoking and an initial open wound are independent risk factors for complications. MATERIALS AND METHODS: We retrospectively included consecutive patients managed for open or closed tibial shaft fractures by primary intramedullary nailing between 2013 and 2018. We collected data on preoperative factors related to the patient and to the mechanism of injury (age, sex, smoking history, energy of the trauma, open wound), on intraoperative factors (residual interfragmentary gap), and on postoperative factors (early or delayed weight-bearing). We evaluated the associations between these factors and the occurrence of complications, notably non-union, by performing a univariate analysis followed by a multivariate analysis. RESULTS: We included 184 patients [mean age, 38.5±17.6 (range, 15-91), 72.2% of males]. One or more complications developed in 28 (15.2%) patients and non-union occurred in 15 (8.1%) patients. There were three significant risk factors for complications: active smoking (OR, 7.93; 95%CI, 2.76-22.7), a residual interfragmentary gap &gt;5mm (OR, 4.92; 95%CI, 1.72-14.02), and an initial open wound (OR,5.16; 95%CI, 1.62-16.43) (p5mm, and an initial open wound are risk factors for postoperative complications after intramedullary nailing to treat a tibial shaft fracture. Preventive strategies and specific information could be implemented for these patients. LEVEL OF EVIDENCE: IV; single-centre retrospective cohort study

Ostéotomie transverse de raccourcissement sous-trochantériennne lors de la mise en place d’une PTH dans les luxations congénitales Crowe III–IV : résultats à 12 ans d’une technique d’ostéosynthèse par double haubanage

RésuméIntroductionLors de la réalisation d’une prothèse totale de hanche chez un patient présentant une luxation congénitale de hanche (LCH) de haut grade, le raccourcissement fémoral permet de faciliter la réduction, de prévenir une lésion sciatique et crurale ou un excès de longueur final sur le membre opéré. Il n’existe pas de consensus concernant le type d’implant ou d’ostéosynthèse à utiliser, pourtant de ce choix dépendent directement les risques de complication per- et postopératoires les plus fréquemment retrouvés (fractures diaphysaires, luxations, pseudarthrose). Afin d’essayer de contrôler au mieux ces risques, nous avons mis au point une technique d’ostéotomie transverse de raccourcissement sous-trochantérienne associée à la mise en place d’une tige longue de coupe ovoïde sans ciment à tenue métaphysaire et d’une ostéosynthèse par double haubanage. Les objectifs de cette étude étaient d’analyser les résultats de cette technique en se concentrant sur (1) les complications et la survie de l’implant fémoral, (2) les résultats cliniques (scores fonctionnels et inégalité de longueur des membres inférieurs [ILMI]), (3) le délai de consolidation.HypothèseCette technique permet d’obtenir un faible taux de complications peropératoire et postopératoires.Matériel et méthodeIl s’agissait d’une étude rétrospective monocentrique incluant les patients opérés de 2000 à 2015 d’une prothèse de hanche associée à une ostéotomie de raccourcissement fémorale sous-trochantérienne, fixés par un double haubanage dans le cadre d’une LCH sévère (Crowe III et IV). L’implant fémoral utilisé était une tige longue ovoïde non cimentée recouverte en totalité d’hydroxyapatite. Les complications per- et postopératoires, la survie, l’inégalité de longueur (ILMI), les scores fonctionnels (Harris [HHS]), score de hanche oubliée (Forgotten Joint Score [FJS]), la satisfaction et les résultats radiographiques ont été étudiés.RésultatsTrente et une hanches ont été incluses. Deux patients ont été perdus de vue (6,5 %, 2/31) et exclus des analyses postopératoires. Le suivi moyen était de 13,7 ans±4,2 [5,8–18,3]. Ont été rapportées deux fractures diaphysaires peropératoire (6,5 %, 2/31), une fracture du grand trochanter (3,2 %, 1/31), une lésion sciatique (3,4 %, 1/29) ayant complètement récupéré, soit au total 4/31 (12,9 %) complications peropératoires. En postopératoire nous avons observé 8/31 complications (25,8 %) incluant deux luxations (6,9 %, 2/29), deux enfoncements de tige (6,9 %, 2/29) et quatre pseudarthroses (13,8 %, 4/29). La survie de l’implant fémoral au dernier recul était de 87,1 % (IC95 % [76,1–99,7]). Le HHS moyen est passé de 39,6±12,0 [14–61] en préopératoire à 81,7±13,2 [48–100] au dernier recul (p<0,01). Au dernier recul, 48,2 % (14/29) de hanches étaient déclarées comme oubliées et 31,0 % (9/29) étaient symptomatiques mais non gênantes. Une ILMI significative (≥1cm) était présente chez 8 patients (27,6 %, 8/29) en postopératoire contre 19 (65,5 %, 19/29) en préopératoire, l’ILMI moyenne est passée de 20,8mm±19,7 [0–60] à 5mm±7,3 [0–30]. Le délai de consolidation moyen était de 4,3 mois±2,4 [2–11].ConclusionCette technique présentait peu de complications peropératoires fracturaires ou postopératoires immédiates mais une survie du pivot fémoral inférieure aux données de la littérature et avait un taux de pseudarthrose élevé malgré des résultats postopératoires fonctionnels et cliniques satisfaisants.Niveau de preuveIV

Transverse subtrochanteric shortening osteotomy with double tension-band fixation during THA for Crowe III-IV developmental dysplasia: 12-year outcomes

Background: When performing total hip arthroplasty in patients with severe developmental dysplasia, shortening the femur facilitates reduction while also preventing sciatic or crural nerve injury and excessive length of the operated limb. No consensus exists about the optimal type of implant and best internal fixation procedure, two parameters that directly govern the risk of the most common intraoperative and postoperative complications (diaphyseal fractures, dislocation, non-union). To minimise these risks, we developed a technique combining a transverse subtrochanteric shortening osteotomy, a long ovoid-profiled, cementless stem anchored in the metaphysis, and double tension-band wiring for internal fixation. The primary objective of this study was to evaluate the outcomes of this technique with emphasis on (i) complications and femoral implant survival, (ii) clinical outcomes (functional scores and lower-limb length inequality [LLLI]), and time to healing. Hypothesis: Our technique is associated with low rates of intraoperative and postoperative complications.Material and methods: This single-centre retrospective cohort study included patients who underwent THA with a transverse subtrochanteric shortening osteotomy and fixation using double tension-band wiring to treat severe (Crowe III or IV) developmental hip dysplasia. The femoral implant was a long, ovoid, cementless stem fully coated with hydroxyapatite. We collected the intraoperative and postoperative complications, survival, LLLI, functional scores (Harris Hip Score [HHS] and Forgotten Joint Score [FJS]), patient satisfaction, and radiographic outcomes. Results: The study included 31 hips in 25 patients. Two patients (2/31 hips, 6.5%) were lost to follow-up, leaving 29 hips for the analysis of postoperative outcomes. Mean follow-up was 13.7 ± 4.2 years (range, 5.8–18.3 years). The four intraoperative complications (4/31, 12.9%) consisted fracture of the diaphysis (2/31, 6.5%), fracture of the greater trochanter (1/31, 3.2%), and sciatic nerve injury followed by a full recovery (1/29, 3.4%). The 8 (8/29, 27.5%) postoperative complications consisted of dislocation (2/29, 6.9%), stem subsidence (2/29, 6.9%), and non-union (4/29, 13.8%). Femoral implant survival at last follow-up was 87.1% (95% CI, 76.1–99.7). The mean HHS increased from 39.6 ± 12.0 (range, 14–61) before surgery to 81.7 ± 13.2 (range, 48–100) at last follow-up (p < 0.01). The FJS at last follow-up indicated that the joint was forgotten in 14/29 (48.2%) cases and caused only acceptable symptoms in 9/29 (31.0%) of cases. Clinically significant (≥ 1 cm) LLLI was present in 8/29 (27.6%) patients postoperatively compared to 19/29 (65.5%) preoperatively. The mean LLLI decreased from 20.8 ± 19.7 mm (range, 0–60 mm) to 5.0 ± 7.3 mm (range, 0–30 mm). Mean time to healing was 4.3 ± 2.4 months (range, 2–11 months).Conclusion: Regarding these complex procedures, this technique was associated with low rates of intraoperative fractures and early postoperative complications. However, femoral stem survival was shorter than in earlier studies and the non-union rate was high, despite satisfactory functional and clinical outcomes

War-related extremity injuries in children: 89 cases managed in a combat support hospital in Afghanistan

Background Meeting paediatric needs is among the priorities of western healthcare providers working in Afghanistan. Hypothesis Insufficient information is available on paediatric wartime injuries to the extremities. Our objective here was to describe these injuries and their management on the field. Materials and methods We retrospectively reviewed consecutive cases of injuries to the extremities in children

Evaluation of containment measures’ effect on orthopaedic trauma surgery during the COVID-19 pandemic: a retrospective comparison between 2019 and 2020

There is no available information about the effect of containment measures on trauma surgery activity. The aim of this study was to analyse and report the containment measures' impact on trauma surgery activity during the COVID-19 pandemic in order to quickly react and adjust in case of a new sanitary crisis and containment

Wartime paediatric extremity injuries: experience from the Kabul International Airport Combat support hospital

Since the beginning of Operation Enduring Freedom, management of Afghan military or civilian casualties including children is a priority of the battlefield medical support. The aim of this study is to describe the features of paediatric wartime extremities injuries and to analyse their management in the Kabul International Airport Combat Support Hospital. A retrospective review was carried out using the French surgical database OPEX (Service de Santé des Armées) from June 2009 to January 2013. Paediatric patients were defined as those younger than 16 years old. Of the 220 injured children operated on, 155 (70%) sustained an extremity injury and were included. The mean age of the children was 9.1 ± 3.8 years. Among these children, 77 sustained combat-related injuries (CRIs) and 78 sustained noncombat-related injuries (NCRIs), with a total of 212 extremities injuries analysed. All CRIs were open injuries, whereas NCRIs were dominated by blunt injuries. Multiple extremities injuries and associated injuries were significantly more frequent in children with CRIs, whose median Injury Severity Score was higher than those with NCRIs. Debridement and irrigation was significantly predominant in the CRIs group, as well as internal fracture fixation in the NCRIs group. There were four deaths, yielding a global mortality rate of 2.6%. This study is the first to analyse specifically paediatric extremities trauma and their management at level 3 of battlefield medical facilities in recent conflicts. Except for severe burns and polytrauma, treatment of paediatric extremities injuries can be readily performed in Combat Support Hospitals by orthopaedic surgeons trained in paediatric trauma