European journal of orthopaedic surgery & traumatology : orthopedie traumatologie, 2018
Operative management of scapular body fractures, when indicated, typically involves extensive exp... more Operative management of scapular body fractures, when indicated, typically involves extensive exposure through a posterior approach. We present our experience with a deltoid preserving approach that allows excellent exposure of the fracture lines for reduction and fixation while minimizing muscle detachment and overall tissue trauma. Exposure of the scapula was obtained through a posterior incision. The posterior deltoid was exposed and retracted superiorly while the arm was abducted in accordance with Brodsky et al. The scapula was exposed in the interval between infraspinatus and teres minor. Six patients were treated using this approach and were retrospectively reviewed. All were men with a mean age of 34 years (range 24-45 ± 6.7 years). The injuries involved two 14-A3.1 and four 14-A3.2 AO/OTA types of fractures. The mean follow-up after surgery was 28 months (range 21-36 ± 4.93 months). All fractures could be anatomically reduced and healed without compromise. The mean Constant...
Because of detachment of the pectoralis minor and variation of the vector of the conjoint tendons... more Because of detachment of the pectoralis minor and variation of the vector of the conjoint tendons, we hypothesized that the Latarjet procedure may alter scapular position and motion. The purpose of this study was to evaluate scapular position and motion in patients who underwent a Latarjet or a modified iliac crest bone graft transfer (ICBGT) procedure (J-bone graft). Forty-six consecutive patients treated for recurrent anterior shoulder dislocation between 2010 and 2012 were retrospectively enrolled. Twenty-three were treated with a Latarjet and 23 with an ICBGT procedure. Twenty Latarjet and 20 ICBGT patients were available at a mean follow-up of 20 months (min, 12; max, 60). We recorded the Western Ontario Instability Index, the Rowe Score, and the Subjective Shoulder Value. Scapulothoracic position was studied according to the dyskinesis yes/no method. Intraobserver and interobserver reliability of the dyskinesis assessment was assessed. Intraobserver and interobserver reliability of scapula dyskinesis assessment was high (Latarjet: intratester, κ = 0.84; intertester, κ = 0.75; ICBGT: intratester, κ = 0.78; intertester, κ = 0.71). Scapular dyskinesis was observed after 5 of 20 Latarjet and after 0 of 20 ICBGT procedures (P = .047). Patients with dyskinesis had lower scores (Western Ontario Instability Index, P = .043; Rowe, P = .047; Subjective Shoulder Value, P = .046), but no statistically significant difference was found between the Latarjet and ICBGT groups. Two of the 5 scapular dyskinesis patients reached the SICK (Scapular malposition, Inferior medial scapular winging, Coracoid tenderness, and scapular dysKinesis) scapula syndrome definition. Scapular dyskinesis was found in 5 of 20 patients who underwent a Latarjet procedure. Dyskinesis may be related to the detachment of the pectoralis minor, and variation of the vector and the working length of the coracobrachialis and the short head of the biceps.
The indications and techniques for surgical management of fractures of the proximal humerus remai... more The indications and techniques for surgical management of fractures of the proximal humerus remain controversial, and the results of treatment are often disappointing, with a relatively high complication rate. Anatomic reduction can be difficult, and loss of fixation because of poor bone quality may lead to fracture displacement and malunion. Hemiarthroplasty has a high rate of shoulder stiffness, tuberosity resorption, and glenohumeral instability. There is a wide variety of surgical techniques and implants to treat these fractures, but there is little guidance in the literature on specific indications for their use. Therefore, it is important for orthopaedic surgeons to be familiar with techniques to avoid complications and improve results when treating proximal humerus fractures.
Malrotation has been suggested as a cause of failure of hemiarthroplasty of the proximal humerus.... more Malrotation has been suggested as a cause of failure of hemiarthroplasty of the proximal humerus. Placing a shoulder prosthesis in relationship to the bicipital groove might reproduce individual anatomy more reliably than using a standardized retrotorsion. The purpose of this study was to determine criteria for accurate adjustment of retrotorsion even when the proximal bicipital groove is destroyed, as is the case in fractures. The distance of the humeral head equatorial plane to the center of the bicipital groove was measured by high-resolution computed tomography at 4 levels (proximal and distal with 2 intermediate levels). The distal distance was considered to correspond to available references in fracture cases. The mean proximal distance was 8.0 mm (10th percentile, 6.2 mm; 90th percentile, 9.8 mm), and the mean distal distance was 8.5 mm (10th percentile, 7.1 mm; 90th percentile, 9.9 mm). As to the clinical relevance, there was no statistically significant difference between distances. For practical purposes in fracture indications, it is adequate to adjust the retrotorsion of the prosthetic component to the distal bicipital groove.
Vascularized fibular grafts have proven to have many advantages over nonvascularized transplants ... more Vascularized fibular grafts have proven to have many advantages over nonvascularized transplants for treatment of large segmental bone defects in the extremities. Fibulas are typically impacted into the medullary canal and fixed with wires or screws. Consolidation has often been delayed and full weightbearing was only possible after graft hypertrophy, usually 12 to 18 months after reconstruction. In order to shorten the time of consolidation and to achieve early full weightbearing, the authors propose a sound biomechanical reconstructive concept: a) stable but not devascularizing osteosynthesis of the osteotomy to shorten the time of consolidation; b) a double-strut fibular graft that yields enough strength for early weightbearing, without the need for bone hypertrophy; and c) additional cancellous bone grafts, to enhance the long-term stability of the reconstruction. Seven patients with tibial defects ranging between 6 and 17.5 cm were treated according to this concept. In four cases, free vascularized fibula was transferred first. Six weeks later, a vascularized, ipsilateral fibula-pro-tibia procedure was done, and the space between the fibulas was filled with cancellous bone grafts. In three patients, a free, vascularized, double-barrel, fibula transfer was done, since the tibial defect was less than 10 cm. Cancellous bone grafts between the fibulas were added only 6 weeks later. In five cases, the free fibula transfer was combined with a latissimus dorsi myocutaneous flap. In six patients, healing was uneventful. In one patient, hypoperfusion of the lower extremity and the vascularized grafts eventually resulted in a below-knee amputation. In all six successful cases, union resulted within 3 months.(ABSTRACT TRUNCATED AT 250 WORDS)
To obtain more information on the pattern of damage of prosthetic glenoid components, we analyzed... more To obtain more information on the pattern of damage of prosthetic glenoid components, we analyzed 7 retrieved glenoid components. The consecutive series included 2 standard polyethylene components and 5 highly crystalline polyethylene glenoids (Hylamer; DePuy Dupont Orthopaedics, Warsaw, IN) retrieved 3 to 12 years after implantation. At revision, 4 of 5 Hylamer components were fractured. Common wear patterns were i) deformation and crumbling of the rim, particularly at the inferior hemicircumference, probably caused by direct contact of the humerus with the prosthetic component; ii) roughening (abrasion and scratching) of the adjacent articulating surface; and iii) concentric and congruous wear centered posteriorly. Available glenoid components may cover an excessive sector of the head. This can result in mechanical restriction of glenohumeral motion and abutment of the humerus against the glenoid rim. Abutment may cause major shear forces and therefore cause glenoid loosening. The value of articular surface mismatch is questionable because retrieved glenoids were worn to a conforming joint.
This article presents a quick and effective method using adhesive tapes to prevent ischemia or pe... more This article presents a quick and effective method using adhesive tapes to prevent ischemia or penetration of the skin in clavicle fractures.
Historical evolution in concepts, indications, application, reduction techniques, and the rehabil... more Historical evolution in concepts, indications, application, reduction techniques, and the rehabilitation program and complications of external fixation of the wrist are discussed. Indirect reduction techniques using overdistraction and flexion are recommended. Additional stabilization of the epiphysis allows immediate reduction of overdistraction, thus eliminating the potential complications related to overdistraction. Used with the due attention to detail, external fixation of the wrist is a rewarding and efficient treatment method.
A new, pedicled, reverse flow osteoperiosteal flap based on 2 branches of the descending genicula... more A new, pedicled, reverse flow osteoperiosteal flap based on 2 branches of the descending genicular a. is presented. Both a periosteal and osteoperiosteal flap can be raised at the distal end of the femur and, in favourable cases (64% of the dissections), transported as far as the middle third of the leg. In all other cases the proximal third of the tibia can be reached. Composite musculo-osteoperiosteal flaps can also be raised, including the articularis genus m. Clinical applications may include the treatment of nonunions, reconstruction of segmental tibial defects and bone revascularisation in aseptic necrosis about the knee joint.
Le traitement des fractures des plateaux tibiaux a pour buts de retablir la congruence articulair... more Le traitement des fractures des plateaux tibiaux a pour buts de retablir la congruence articulaire, de restaurer l’axe du membre lese et de permettre la guerison adequate des tissus mous. Il faut maintenir une mobilite articulaire satisfaisante et prevenir l’arthrose post-traumatique. Le traitement optimal de ces fractures est controverse. Les options therapeutiques proposees sont nombreuses : mobilisation precoce sous traction, guetre plâtree, fixateur externe, reduction ouverte et osteosynthese, osteosynthese mini-invasive, mais aussi osteosynthese percutanee apres reduction indirecte et/ou assistee par arthroscopie (1-3, 6-12, 15-20, 22, 26-30, 33). Pour des fractures qui presentent un deplacement significatif, ou associees a une laxite articulaire notable, l’osteosynthese a foyer ouvert est le traitement habituel (2, 6, 21, 22, 26, 30). Un taux de complications eleve, notamment infectieuses, dans certains types de fractures, entre autres a haute energie, ou apres certains traitements, tels les doubles plaques mediale et laterale (6, 18, 21, 26, 28, 31, 32), a conduit quelques auteurs a des traitements moins invasifs ; la diminution des taux de complications septiques et la preservation des tissus par ces methodes dites mini-invasives se paient en contrepartie par une reduction moins precise de la fracture (7, 11, 15, 16, 20, 24).
Conclusion La face interne de l'extrémité distale du fémur constitue un site donneur inté... more Conclusion La face interne de l'extrémité distale du fémur constitue un site donneur intéressant de périoste et d'os vascularisé. Un long pédicule inversé permet des transferts tissulaires (périoste, ostéopériosté ou musculo-ostéopériosté) jusqu'au tiers moyen du tibia. L'importance des variations anatomiques justifie une évaluation pré-opératoire de la disposition vasculaire.
The Journal of Trauma: Injury, Infection, and Critical Care, 2006
Close Window. Close Window. Thank you for choosing to subscribe to the eTOC for The Journal of Tr... more Close Window. Close Window. Thank you for choosing to subscribe to the eTOC for The Journal of Trauma. Enter your Email address: Wolters Kluwer Health may email you for journal alerts and information, but is committed to ...
The purpose of this study was to add critical information to the data already available on anthro... more The purpose of this study was to add critical information to the data already available on anthropometry of the proximal humerus. Two hundred macerated humeri were examined. Measurements were taken either directly on the bones or on standardized radiographic projections. The methodology was validated and showed a mean interobserver correlation of 0.94 +/- 0.067. Results were expressed in mean values, first SD, and minimum and maximum values, as well as the 10th and 90th percentiles. The frontal radius of the head ranged between 21 and 26.5 mm (10th respectively 90th percentile). The frontal diameter of the base of the head ranged between 39.4 and 50 mm. The head height ranged between 14.4 and 18.8 mm. The frontal radius-head height ratio ranged between 0.64 and 0.77. The inclination of the head ranged between 132 degrees and 142 degrees. The medial offset ranged between 3.9 and 8.6 mm. The posterior offset ranged between -0.4 and 3.2 mm. The greater tuberosity offset (distance between the axis of the proximal humerus and the most medial insertion point of the supraspinatus tendon) ranged between 2.5 and 9.2 mm. Retrotorsion ranged between 7 degrees and 38.5 degrees. The distance from the bicipital groove to the head equator ranged between 6 and 10.5 mm. The anatomy of the proximal humerus showed a wide range for variables such as the medial offset and the greater tuberosity offset but was surprisingly constant for the inclination and relative dimensions of the head. The implications for prosthetic design are as follows: stem design and insertion should respect the insertion facet of the supraspinatus, a constant head inclination is an adequate approximation, only one head height per radius is required, and the capability for adjustment of medial offset is mandatory.
European journal of orthopaedic surgery & traumatology : orthopedie traumatologie, 2018
Operative management of scapular body fractures, when indicated, typically involves extensive exp... more Operative management of scapular body fractures, when indicated, typically involves extensive exposure through a posterior approach. We present our experience with a deltoid preserving approach that allows excellent exposure of the fracture lines for reduction and fixation while minimizing muscle detachment and overall tissue trauma. Exposure of the scapula was obtained through a posterior incision. The posterior deltoid was exposed and retracted superiorly while the arm was abducted in accordance with Brodsky et al. The scapula was exposed in the interval between infraspinatus and teres minor. Six patients were treated using this approach and were retrospectively reviewed. All were men with a mean age of 34 years (range 24-45 ± 6.7 years). The injuries involved two 14-A3.1 and four 14-A3.2 AO/OTA types of fractures. The mean follow-up after surgery was 28 months (range 21-36 ± 4.93 months). All fractures could be anatomically reduced and healed without compromise. The mean Constant...
Because of detachment of the pectoralis minor and variation of the vector of the conjoint tendons... more Because of detachment of the pectoralis minor and variation of the vector of the conjoint tendons, we hypothesized that the Latarjet procedure may alter scapular position and motion. The purpose of this study was to evaluate scapular position and motion in patients who underwent a Latarjet or a modified iliac crest bone graft transfer (ICBGT) procedure (J-bone graft). Forty-six consecutive patients treated for recurrent anterior shoulder dislocation between 2010 and 2012 were retrospectively enrolled. Twenty-three were treated with a Latarjet and 23 with an ICBGT procedure. Twenty Latarjet and 20 ICBGT patients were available at a mean follow-up of 20 months (min, 12; max, 60). We recorded the Western Ontario Instability Index, the Rowe Score, and the Subjective Shoulder Value. Scapulothoracic position was studied according to the dyskinesis yes/no method. Intraobserver and interobserver reliability of the dyskinesis assessment was assessed. Intraobserver and interobserver reliability of scapula dyskinesis assessment was high (Latarjet: intratester, κ = 0.84; intertester, κ = 0.75; ICBGT: intratester, κ = 0.78; intertester, κ = 0.71). Scapular dyskinesis was observed after 5 of 20 Latarjet and after 0 of 20 ICBGT procedures (P = .047). Patients with dyskinesis had lower scores (Western Ontario Instability Index, P = .043; Rowe, P = .047; Subjective Shoulder Value, P = .046), but no statistically significant difference was found between the Latarjet and ICBGT groups. Two of the 5 scapular dyskinesis patients reached the SICK (Scapular malposition, Inferior medial scapular winging, Coracoid tenderness, and scapular dysKinesis) scapula syndrome definition. Scapular dyskinesis was found in 5 of 20 patients who underwent a Latarjet procedure. Dyskinesis may be related to the detachment of the pectoralis minor, and variation of the vector and the working length of the coracobrachialis and the short head of the biceps.
The indications and techniques for surgical management of fractures of the proximal humerus remai... more The indications and techniques for surgical management of fractures of the proximal humerus remain controversial, and the results of treatment are often disappointing, with a relatively high complication rate. Anatomic reduction can be difficult, and loss of fixation because of poor bone quality may lead to fracture displacement and malunion. Hemiarthroplasty has a high rate of shoulder stiffness, tuberosity resorption, and glenohumeral instability. There is a wide variety of surgical techniques and implants to treat these fractures, but there is little guidance in the literature on specific indications for their use. Therefore, it is important for orthopaedic surgeons to be familiar with techniques to avoid complications and improve results when treating proximal humerus fractures.
Malrotation has been suggested as a cause of failure of hemiarthroplasty of the proximal humerus.... more Malrotation has been suggested as a cause of failure of hemiarthroplasty of the proximal humerus. Placing a shoulder prosthesis in relationship to the bicipital groove might reproduce individual anatomy more reliably than using a standardized retrotorsion. The purpose of this study was to determine criteria for accurate adjustment of retrotorsion even when the proximal bicipital groove is destroyed, as is the case in fractures. The distance of the humeral head equatorial plane to the center of the bicipital groove was measured by high-resolution computed tomography at 4 levels (proximal and distal with 2 intermediate levels). The distal distance was considered to correspond to available references in fracture cases. The mean proximal distance was 8.0 mm (10th percentile, 6.2 mm; 90th percentile, 9.8 mm), and the mean distal distance was 8.5 mm (10th percentile, 7.1 mm; 90th percentile, 9.9 mm). As to the clinical relevance, there was no statistically significant difference between distances. For practical purposes in fracture indications, it is adequate to adjust the retrotorsion of the prosthetic component to the distal bicipital groove.
Vascularized fibular grafts have proven to have many advantages over nonvascularized transplants ... more Vascularized fibular grafts have proven to have many advantages over nonvascularized transplants for treatment of large segmental bone defects in the extremities. Fibulas are typically impacted into the medullary canal and fixed with wires or screws. Consolidation has often been delayed and full weightbearing was only possible after graft hypertrophy, usually 12 to 18 months after reconstruction. In order to shorten the time of consolidation and to achieve early full weightbearing, the authors propose a sound biomechanical reconstructive concept: a) stable but not devascularizing osteosynthesis of the osteotomy to shorten the time of consolidation; b) a double-strut fibular graft that yields enough strength for early weightbearing, without the need for bone hypertrophy; and c) additional cancellous bone grafts, to enhance the long-term stability of the reconstruction. Seven patients with tibial defects ranging between 6 and 17.5 cm were treated according to this concept. In four cases, free vascularized fibula was transferred first. Six weeks later, a vascularized, ipsilateral fibula-pro-tibia procedure was done, and the space between the fibulas was filled with cancellous bone grafts. In three patients, a free, vascularized, double-barrel, fibula transfer was done, since the tibial defect was less than 10 cm. Cancellous bone grafts between the fibulas were added only 6 weeks later. In five cases, the free fibula transfer was combined with a latissimus dorsi myocutaneous flap. In six patients, healing was uneventful. In one patient, hypoperfusion of the lower extremity and the vascularized grafts eventually resulted in a below-knee amputation. In all six successful cases, union resulted within 3 months.(ABSTRACT TRUNCATED AT 250 WORDS)
To obtain more information on the pattern of damage of prosthetic glenoid components, we analyzed... more To obtain more information on the pattern of damage of prosthetic glenoid components, we analyzed 7 retrieved glenoid components. The consecutive series included 2 standard polyethylene components and 5 highly crystalline polyethylene glenoids (Hylamer; DePuy Dupont Orthopaedics, Warsaw, IN) retrieved 3 to 12 years after implantation. At revision, 4 of 5 Hylamer components were fractured. Common wear patterns were i) deformation and crumbling of the rim, particularly at the inferior hemicircumference, probably caused by direct contact of the humerus with the prosthetic component; ii) roughening (abrasion and scratching) of the adjacent articulating surface; and iii) concentric and congruous wear centered posteriorly. Available glenoid components may cover an excessive sector of the head. This can result in mechanical restriction of glenohumeral motion and abutment of the humerus against the glenoid rim. Abutment may cause major shear forces and therefore cause glenoid loosening. The value of articular surface mismatch is questionable because retrieved glenoids were worn to a conforming joint.
This article presents a quick and effective method using adhesive tapes to prevent ischemia or pe... more This article presents a quick and effective method using adhesive tapes to prevent ischemia or penetration of the skin in clavicle fractures.
Historical evolution in concepts, indications, application, reduction techniques, and the rehabil... more Historical evolution in concepts, indications, application, reduction techniques, and the rehabilitation program and complications of external fixation of the wrist are discussed. Indirect reduction techniques using overdistraction and flexion are recommended. Additional stabilization of the epiphysis allows immediate reduction of overdistraction, thus eliminating the potential complications related to overdistraction. Used with the due attention to detail, external fixation of the wrist is a rewarding and efficient treatment method.
A new, pedicled, reverse flow osteoperiosteal flap based on 2 branches of the descending genicula... more A new, pedicled, reverse flow osteoperiosteal flap based on 2 branches of the descending genicular a. is presented. Both a periosteal and osteoperiosteal flap can be raised at the distal end of the femur and, in favourable cases (64% of the dissections), transported as far as the middle third of the leg. In all other cases the proximal third of the tibia can be reached. Composite musculo-osteoperiosteal flaps can also be raised, including the articularis genus m. Clinical applications may include the treatment of nonunions, reconstruction of segmental tibial defects and bone revascularisation in aseptic necrosis about the knee joint.
Le traitement des fractures des plateaux tibiaux a pour buts de retablir la congruence articulair... more Le traitement des fractures des plateaux tibiaux a pour buts de retablir la congruence articulaire, de restaurer l’axe du membre lese et de permettre la guerison adequate des tissus mous. Il faut maintenir une mobilite articulaire satisfaisante et prevenir l’arthrose post-traumatique. Le traitement optimal de ces fractures est controverse. Les options therapeutiques proposees sont nombreuses : mobilisation precoce sous traction, guetre plâtree, fixateur externe, reduction ouverte et osteosynthese, osteosynthese mini-invasive, mais aussi osteosynthese percutanee apres reduction indirecte et/ou assistee par arthroscopie (1-3, 6-12, 15-20, 22, 26-30, 33). Pour des fractures qui presentent un deplacement significatif, ou associees a une laxite articulaire notable, l’osteosynthese a foyer ouvert est le traitement habituel (2, 6, 21, 22, 26, 30). Un taux de complications eleve, notamment infectieuses, dans certains types de fractures, entre autres a haute energie, ou apres certains traitements, tels les doubles plaques mediale et laterale (6, 18, 21, 26, 28, 31, 32), a conduit quelques auteurs a des traitements moins invasifs ; la diminution des taux de complications septiques et la preservation des tissus par ces methodes dites mini-invasives se paient en contrepartie par une reduction moins precise de la fracture (7, 11, 15, 16, 20, 24).
Conclusion La face interne de l'extrémité distale du fémur constitue un site donneur inté... more Conclusion La face interne de l'extrémité distale du fémur constitue un site donneur intéressant de périoste et d'os vascularisé. Un long pédicule inversé permet des transferts tissulaires (périoste, ostéopériosté ou musculo-ostéopériosté) jusqu'au tiers moyen du tibia. L'importance des variations anatomiques justifie une évaluation pré-opératoire de la disposition vasculaire.
The Journal of Trauma: Injury, Infection, and Critical Care, 2006
Close Window. Close Window. Thank you for choosing to subscribe to the eTOC for The Journal of Tr... more Close Window. Close Window. Thank you for choosing to subscribe to the eTOC for The Journal of Trauma. Enter your Email address: Wolters Kluwer Health may email you for journal alerts and information, but is committed to ...
The purpose of this study was to add critical information to the data already available on anthro... more The purpose of this study was to add critical information to the data already available on anthropometry of the proximal humerus. Two hundred macerated humeri were examined. Measurements were taken either directly on the bones or on standardized radiographic projections. The methodology was validated and showed a mean interobserver correlation of 0.94 +/- 0.067. Results were expressed in mean values, first SD, and minimum and maximum values, as well as the 10th and 90th percentiles. The frontal radius of the head ranged between 21 and 26.5 mm (10th respectively 90th percentile). The frontal diameter of the base of the head ranged between 39.4 and 50 mm. The head height ranged between 14.4 and 18.8 mm. The frontal radius-head height ratio ranged between 0.64 and 0.77. The inclination of the head ranged between 132 degrees and 142 degrees. The medial offset ranged between 3.9 and 8.6 mm. The posterior offset ranged between -0.4 and 3.2 mm. The greater tuberosity offset (distance between the axis of the proximal humerus and the most medial insertion point of the supraspinatus tendon) ranged between 2.5 and 9.2 mm. Retrotorsion ranged between 7 degrees and 38.5 degrees. The distance from the bicipital groove to the head equator ranged between 6 and 10.5 mm. The anatomy of the proximal humerus showed a wide range for variables such as the medial offset and the greater tuberosity offset but was surprisingly constant for the inclination and relative dimensions of the head. The implications for prosthetic design are as follows: stem design and insertion should respect the insertion facet of the supraspinatus, a constant head inclination is an adequate approximation, only one head height per radius is required, and the capability for adjustment of medial offset is mandatory.
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