Publications by authors named "Alain Sautet"

29 Publications

  • Page 1 of 1

Use of Gracile and semi-tendinosus tendons (GRAST) for the reconstruction of irreparable rotator cuff tears.

BMC Musculoskelet Disord 2021 Apr 5;22(1):331. Epub 2021 Apr 5.

Unité de chirurgie du membre supérieur, Clinique Saint Jean l'Ermitage, 272 avenue Marc Jacquet, 77000, Melun, France.

Background: Irreparable rotator cuff tears are common and difficult to treat. Techniques for "filling the loss of substance" require fixation to the rotator cuff stump (tendon augmentation) or to the glenoid (superior capsular reconstruction), which are complicated by the narrow working zone of the subacromial space. The main objective of this study was to determine whether a braided graft of gracilis (GR) and semitendinosus (ST) could fill a loss of tendon substance from an irreparable rupture of the supra- and infraspinatus, by fixing the graft to the greater tuberosity and the spine of the scapula.

Methods: This was a cadaveric study with the use of ten specimens. The GRA and ST tendons were harvested, braided and reinforced with suture. An experimental tear of the supraspinatus (SS) and upper infraspinatus (IS) retracted at the glenoid was made. The GRAST transplant was positioned over the tear. The transplant was attached to the greater tuberosity by two anchors and then attached to the medial third of the scapular spine by trans-osseous stitching. The percentage of filling obtained was then measured and passive mobility of the shoulder was assessed. We proceeded to the same technique under arthroscopy for a 73 years old patient whom we treated for a painful shoulder with irreparable cuff tear. We inserted a GRAST graft using arthroscopy.

Results: The Braided-GRAST allowed a 100% filling of the loss of tendon substance. Mobility was complete in all cases.

Conclusion: This technique simplifies the medial fixation and restores the musculo-tendinous chain where current grafting techniques only fill a tendinous defect. The transplant could have a subacromial "spacer" effect and lower the humeral head. The donor site morbidity and the fate of the transplant in-vivo are two limits to be discussed. This anatomical study paves the way for clinical experimentation.
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http://dx.doi.org/10.1186/s12891-021-04197-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020539PMC
April 2021

Impact of delayed patient flow on surgical outcomes after hip fracture: An observational study.

Eur J Anaesthesiol 2021 03;38 Suppl 1:S67-S68

From the Department of Anesthesiology and Intensive Care, Hôpital Saint-Antoine, Assistance Publique - Hôpitaux de Paris (IDC, ASo, FB, TL, FV), Unité de Santé Publique, The Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Hôpital Saint-Antoine, AP-HP, Paris, France (PB, NL), Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA (EST, FV), Department of Geriatrics, Saint Antoine Hospital (LM), Department of Orthopaedic Surgery, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (ASa, EB) and Faculté de Médecine Pierre & Marie Curie, The Sorbonne University, Paris, France (FB, TL, FV).

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http://dx.doi.org/10.1097/EJA.0000000000001271DOI Listing
March 2021

Comparison of "Bilboquet" device and locking plate for surgical treatment of proximal humerus complex fractures at two years follow-up.

Int Orthop 2021 07 24;45(7):1811-1816. Epub 2021 Feb 24.

Département de chirurgie orthopédique et traumatologie, Hopital Henri-Mondor, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France.

Purpose: Surgical treatment of three or four part fractures of the proximal humerus is complex. Different conservative techniques have been described. The main goal of this study was to compare the clinical and radiological outcomes of Bilboquet and locking plate at two year follow-up.

Methods: This is a retrospective, comparative study, with a continuous series of 41 patients. Bony fixation was achieved with a Bilboquet device in 22 patients or a locking plate in 19 patients. Patient evaluation included clinical data: shoulder range of motion, Constant-Murley shoulder score and DASH (Disabilities of the Arm, Shoulder and Hand) score, and imaging using standard shoulder X-rays.

Results: Of the 41 patients included, 1 patient was lost to follow-up in the locking plate group. At a mean follow-up of 24 months patients in Bilboquet group showed a Constant score higher than in locking plate (p = 0.02). Range of motion and DASH score were not significantly different between the two groups. avascular necrosis occured in three patients of Bilboquet group (14%) versus in two patients in the locking plate group (11%) (p > 0.5). Complication and reintervention rate were non-significantly higher in the locking plate group than in the Bilboquet group (37 vs 14%).

Conclusion: Bilboquet and locking plate give good functional outcomes in complex proximal humerus fractures. However, the Bilboquet device appears to provide better functional results than locking plate at mid-term follow-up.
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http://dx.doi.org/10.1007/s00264-021-04967-wDOI Listing
July 2021

Impact of Regional Block Failure in Ambulatory Hand Surgery on Patient Management: A Cohort Study.

J Clin Med 2020 Jul 31;9(8). Epub 2020 Jul 31.

Department of Anesthesiology and Intensive Care, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France.

Regional anesthesia (RA) is an anesthetic technique essential for the performance of ambulatory surgery. Failure rates range from 6% to 20%, and the consequences of these failures have been poorly investigated. We determined the incidence and the impact of regional block failure on patient management in the ambulatory setting. This retrospective cohort study includes all adult patients who were admitted to a French University Hospital (Hôpital Saint-Antoine, AP-HP) between 1 January 2016 and 31 December 2017 for unplanned ambulatory distal upper limb surgery. Univariate and stepwise multivariate analyses were performed to determine factors associated with block failure. Among the 562 patients included, 48 (8.5%) had a block failure. RA failure was associated with a longer surgery duration ( = 0.02), more frequent intraoperative analgesics administration ( < 0.01), increased incidence of unplanned hospitalizations ( < 0.001), and a 39% prolongation of Post-Anesthesia Care Unit (PACU) length of stay ( < 0.0001). In the multivariate analysis, the risk factors associated with block failure were female sex ( = 0.04), an American Society of Anesthesiologists (ASA) score > 2 ( = 0.03), history of substance abuse ( = 0.01), and performance of the surgery outside of the specific ambulatory surgical unit ( = 0.01). Here, we have documented a significant incidence of block failure in ambulatory hand surgery, with impairment in the organization of care. Identifying patients at risk of failure could help improve their management, especially by focusing on providing care in a dedicated ambulatory circuit.
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http://dx.doi.org/10.3390/jcm9082453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7463571PMC
July 2020

Open reduction and internal fixation of three- and four-part proximal humeral fractures by intrafocal distraction: a clinical and radiographic study of thirty-two cases with five to ten years of follow-up.

Int Orthop 2020 10 21;44(10):2101-2112. Epub 2020 Jun 21.

Department of Orthopedic Surgery and Traumatology, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.

Purpose: The disadvantage of ORIF of proximal humerus fracture (PHF) by intrafocal distraction is that once the device is inserted, it cannot be removed. This study was designed to evaluate the tolerance of such a titanium alloy device at five years of minimal follow-up (FU) and secondarily to assess the relevance of the osteosynthesis of these fractures.

Method: Thirty-two patients operated for PHF and implanted with a titanium alloy device between 2009 and 2011 were reviewed: fifteen three-part fracture (3-PF) with mean age 65.2 ± seven years and mean FU at 86 months, and seventeen four-part (4-PF) with mean age 62.9 ± 12 years and mean FU at 88 months.

Results: There were no signs of clinical or radiological incompatibility to the metal. The lateral cortex of the humeral shaft at the wedge component level of the device was thinner than pre-operatively in half of the cases. For the fifteen 3-PF, the median raw and weighted constant score (CS) were 75 and 100, respectively. Only one case presented avascular necrosis (AVN). For the seventeen 4-PF, the median raw and weighted CS were 64 and 88, respectively. Seven cases presented AVN and none of them seven had initially a dorsomedial metaphyseal extension of the humeral head. Kaplan-Meier survivorship analysis, with 95% confidence interval, was calculated at 89.7% (79.7-100%) survivorship at 7.18 years of follow-up.

Conclusions: This study shows no incompatibility of the titanium alloy device, radiological signs of localized stress shielding in half of the cases with no functional impact, excellent clinical and radiological evolution of the 3-PF, and AVN in all 4-PF without dorsomedial metaphyseal extension of the humeral head whereas most of cases without AVN had dorsomedial metaphyseal extension.
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http://dx.doi.org/10.1007/s00264-020-04657-zDOI Listing
October 2020

Clearing method for 3-dimensional immunofluorescence of osteoarthritic subchondral human bone reveals peripheral cholinergic nerves.

Sci Rep 2020 06 1;10(1):8852. Epub 2020 Jun 1.

Sorbonne Université, Paris, France.

The cholinergic system plays a major anti-inflammatory role in many diseases through acetylcholine (Ach) release after vagus nerve stimulation. Osteoarthritis (OA) is associated with local low-grade inflammation, but the regulatory mechanisms are unclear. Local Ach release could have anti-inflammatory activity since articular cells express Ach receptors involved in inflammatory responses. Using the 3DISCO clearing protocol that allows whole-sample 3-dimensional (3D) analysis, we cleared human OA cartilage-subchondral bone samples to search for cholinergic nerve fibres able to produce Ach locally. We analysed 3 plugs of knee cartilage and subchondral bone from 3 OA patients undergoing arthroplasty. We found no nerves in the superficial and intermediate articular cartilage layers, as evidenced by the lack of Peripherin staining (a peripheral nerves marker). Conversely, peripheral nerves were found in the deepest layer of cartilage and in subchondral bone. Some nerves in the subchondral bone samples were cholinergic because they coexpressed peripherin and choline acetyltransferase (ChAT), a specific marker of cholinergic nerves. However, no cholinergic nerves were found in the cartilage layers. It is therefore feasible to clear human bone to perform 3D immunofluorescence. Human OA subchondral bone is innervated by cholinergic fibres, which may regulate local inflammation through local Ach release.
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http://dx.doi.org/10.1038/s41598-020-65873-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7264130PMC
June 2020

Anatomy of the posterior branch of the medial antebrachial cutaneous nerve: A cadaveric study.

Orthop Traumatol Surg Res 2020 Jun 29;106(4):771-774. Epub 2020 Apr 29.

Hopital Saint Antoine, Sorbonne Universite, Faculté de Medecine, Campus Saint-Antoine, France.

Purpose: The posterior branch of the medial antebrachial cutaneous nerve (MACN) is at risk to be damaged during cubital tunnel surgery. The purpose of this study was to identify the location of the posterior branch of the MACN (PBMACN) in relation to surgical landmarks pertinent in cubital tunnel surgery.

Methods: We performed an anatomical study on 20 limbs from 13 fresh cadavers. The nerve was dissected from 10cm proximal to 10cm distal of the medial epicondyle. We measured the distance between the nerve and the medial epicondyle, and also the distance separating the PBMACN from the ulnar nerve passage between the two heads of the flexor carpi ulnaris. Measurements were performed with the elbow at 45° and 90° of flexion, as well as in full pronation and supination.

Results: After its emergence from the main trunk of the MACN, the posterior branch ran anteriorly to the medial epicondyle, taking an oblique direction toward the ulnar shaft. The PBMACN was in average 2.53cm under the medial epicondyle when the elbow was flexed at 45°, and 2.96cm when the elbow was flexed at 90°. Average distance between the PBMACN and the penetrating point of the ulnar nerve within the flexor carpi ulnaris was 1.54cm when the elbow was flexed at 45°, and 1.62cm when the elbow was flexed at 90°. Pronation and supination positions of the forearm did not significantly modify our measurements.

Conclusions: Understanding the position of MACN posterior branch during ulnar nerve release surgery at the elbow may help in preventing iatrogenic injury. According to our measurements, incision and superficial dissection anterior to the medial epicondyle or distal to the ulnar nerve penetrating point between the two heads of the flexor carpi ulnaris should be avoided or done with an elbow flexed at 90°.
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http://dx.doi.org/10.1016/j.otsr.2020.02.006DOI Listing
June 2020

Reconstruction of lateral pinch in an isolated paralysis of the first dorsal interosseous muscle - A new surgical technique.

Orthop Traumatol Surg Res 2020 04 7;106(2):353-356. Epub 2020 Feb 7.

Department of orthopedics and hand surgery, Saint-Antoine hospital, Paris, France.

Lack of function of the first interosseous muscle (FDI) might be responsible for insufficient stabilisation of the index finger during lateral pinch, and may induce disability in hand function. The first cause of FDI palsy is ulnar nerve palsy. We describe a new tendon transfer to reanimate the FDI muscle, using the extensor indicis proprius tendon. The tendon is sectioned at its distal insertion and rerouted in the first extensor tendon compartment. We report one case of isolated first interosseous muscle palsy secondary to direct trauma. Preoperatively, the patient complained of a severe lack of strength during key pinch with an ulnarly deviated index finger. Thirty months postoperatively, the patient recovered active abduction of the index finger and lateral pinch was measured at 5.5kg (54N). Compared to the original Bunnell transfer our technique restores the native moment arm of the FDI muscle and does not require a tendon graft.
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http://dx.doi.org/10.1016/j.otsr.2019.08.024DOI Listing
April 2020

Three-dimensional-printed patient-specific Kirschner-wire guide for percutaneous fixation of undisplaced scaphoid fractures: a cadaveric study.

J Hand Surg Eur Vol 2019 Sep 2;44(7):692-696. Epub 2019 Jun 2.

1 Orthopaedic and Traumatology Department, Saint-Antoine Hospital, Paris, France.

Undisplaced scaphoid waist fractures can be managed by percutaneous fixation. The purpose of this study is to compare percutaneous fixation using a three-dimensional (3-D)-printed guide with the conventional method in a cadaveric study. Twelve wrists were divided into two groups: standard fluroscopic technique group, and a patient-specific 3-D-printed guide group. In the patient-specific group, using high resolution CT scans, we manufactured a mould-guide including a wire guide sleeve aligned with the planned ideal path, and 3-D printed it. On postoperative CT scans we measured the angular deviation of the screw axis from the ideal axis, and compared the two groups. The angular deviation was significantly lower in the patient-specific guide group. We concluded that a 3-D-printed guide for scaphoid percutaneous fixation allows a more accurate placement of the screw than a fluoroscopy guide in our cadaveric model.
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http://dx.doi.org/10.1177/1753193419851525DOI Listing
September 2019

Impairment of glyoxalase-1, an advanced glycation end-product detoxifying enzyme, induced by inflammation in age-related osteoarthritis.

Arthritis Res Ther 2019 01 11;21(1):18. Epub 2019 Jan 11.

Sorbonne University, UPMC Univ Paris 06, Paris, France.

Background: Accumulation of advanced glycation end-products (AGEs) is involved in age-related osteoarthritis (OA). Glyoxalase (Glo)-1 is the main enzyme involved in the removal of AGE precursors, especially carboxymethyl-lysine (CML). We aimed to investigate the expression of several AGEs and Glo-1 in human OA cartilage and to study chondrocytic Glo-1 regulation by inflammation, mediated by interleukin (IL)-1β.

Methods: Ex vivo, we quantified AGEs (pentosidine, CML, methylglyoxal-hydroimidazolone-1) in knee cartilage from 30 OA patients. Explants were also incubated with and without IL-1β, and we assessed Glo-1 protein expression and enzymatic activity. In vitro, primary cultured murine chondrocytes were stimulated with increasing concentrations of IL-1β to assess Glo-1 enzymatic activity and expression. To investigate the role of oxidative stress in the IL-1β effect, cells were also treated with inhibitors of mitochondrial oxidative stress or nitric oxide synthase.

Results: Ex vivo, only the human cartilage CML content was correlated with patient age (r = 0.78, p = 0.0031). No statistically significant correlation was found between Glo-1 protein expression and enzymatic activity in human cartilage and patient age. We observed that cartilage explant stimulation with IL-1β decreased Glo-1 protein expression and enzymatic activity. In vitro, we observed a dose-dependent decrease in Glo-1 mRNA, protein quantity, and enzymatic activity in response to IL-1β in murine chondrocytes. Inhibitors of oxidative stress blunted this downregulation.

Conclusion: Glo-1 is impaired by inflammation mediated by IL-1β in chondrocytes through oxidative stress pathways and may explain age-dependent accumulation of the AGE CML in OA cartilage.
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http://dx.doi.org/10.1186/s13075-018-1801-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6330409PMC
January 2019

Comparative effectiveness of direct oral anticoagulants versus low-molecular weight heparins for the prevention of venous thromboembolism after total hip or knee replacement: A nationwide database cohort study.

Pharmacol Res 2019 03 21;141:201-207. Epub 2018 Dec 21.

Bordeaux Pharmacoepi, Inserm CIC1401, Bordeaux University, 33076, Bordeaux, France; INSERM U1219, Bordeaux, 33076, France.

Background: Venous thromboembolism (VTE) after total knee or hip replacement (TKR, THR) is usually prevented with low-molecular weight heparin (LMWH), and increasingly by direct oral anticoagulants (DOAC). The aim of the present study was to compare the benefit-risk and medical costs of DOAC vs. LMWH in a real-life setting.

Methods: All patients with THR or TKR in France between Jan-1st 2013 and Sep-30th 2014, discharged to home, were identified and followed-up for 3 months in the French nationwide claims database, SNDS. DOAC users were 1:1 matched with LWMH users on gender, age and propensity score. Relative risks (RR) of hospitalized VTE, hospitalized bleeding and death were estimated using quasi-Poisson models. Medical costs were calculated according to the societal perspective, including total cost for outpatient claims and national DRG costs for hospitalisations.

Results: Most DOAC users (≥ 98.8%) were matched to a LMWH patient. For the 63,238 matched THR patients, the 3-month absolute risk of VTE was 0.9‰ with DOAC and 2.5‰ with LMWH (RR = 0.35 [0.23 to 0.54]), of bleeding 1.8‰ and 2.1‰ (0.88 [0.62-1.25]), death 0.7‰ and 1.1‰ (0.68 [0.40-1.15]). For the 31,440 matched TKR patients, risks were 1.6‰ and 2.3‰ (0.69 [0.42-1.16]) for VTE, 2.4‰ and 3.8‰ (0.64 [0.43 to 0.97]) for bleeding, and 0.6‰ and 0.8‰ (0.69 [0.30-1.62]) for all-cause death. Mean medical costs were 28% and 21% lower with DOAC than LMWH for THR and TKR, respectively. This nationwide study found a very low risk of VTE, hospitalized bleeding and death after THR or TKR discharge in patients with VTE prevention in real-life setting, with better benefit-risk profiles of DOAC compared to LMWH, and associated cost savings.
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http://dx.doi.org/10.1016/j.phrs.2018.12.018DOI Listing
March 2019

Hemiarthroplasty for proximal humerus fractures with conservation of the whole humeral head as autograft: does it improve greater tuberosity healing?

Int Orthop 2019 05 11;43(5):1155-1164. Epub 2018 Jul 11.

Department of Orthopedic Surgery and Traumatology, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.

Purpose: Hemiarthroplasty (HA) for proximal humerus fracture (PHF) is associated with tuberosity complications like migration, non-union, and resorption. In order to improve the rate of consolidation of the greater tuberosity (GT), we have developed a hollow humeral head prosthesis in which the whole humeral head is inserted and used as autograft. This study is designed to evaluate the consolidation rate of the GT with this device.

Method: Twenty-two patients at mean age of 68 were treated between 2015 and 2017 for four-part fractures, fracture-dislocations, and head-split fractures with HA including the bony humeral head. The humeral prosthesis device comprises a prosthetic cephalic cup in which the detached humeral head is inserted and a cementless adjustable humeral stem which works like a jack. Mean follow-up was 14 months. The consolidation of GT was followed on X-rays. As comparison, 15 published series were selected and analyzed.

Results: There were two mechanical complications related to GT consolidation (9.1%). In the 20 other cases, the GT was radiologically consolidated without displacement. While the raw proportion of complications observed in the present series was lower than that reported in each of the 15 comparative series, the proportion of complications observed in the present series was significantly different from that observed only in seven out of the 15 previous series.

Conclusion: Whole conservation of the humeral head as an autograft along with proper surgical technique yielded in 20 consolidations of GT without displacement in 22 cases of PHF treated with hemiarthroplasty.
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http://dx.doi.org/10.1007/s00264-018-3995-7DOI Listing
May 2019

Cardiometabolic risk factors in primary centred and rotator cuff-related shoulder osteoarthritis: a comparative study.

RMD Open 2017 29;3(1):e000429. Epub 2017 Jun 29.

Rheumatology Department, Saint-Antoine hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Univ Paris 06, Inserm UMRS_938, DHU i2B, Paris, France.

Background: Risk factors for shoulder osteoarthritis (SOA) have been poorly studied. SOA has two anatomical subtypes: primary centred SOA (centred SOA) and rotator cuff-related OA (non-centred SOA). We examined whether cardiometabolic risk factors are preferentially associated with centred than mechanical-induced non-centred SOA.

Methods: This 2004-2012 retrospective multicentric study included patients with SOA. Data on clinical characteristics, especially cardiometabolic risk factors, were collected. We compared patients with radiographic-centred and non-centred SOA and tested the association between cardiometabolic risk factors and subtypes of SOA.

Results: We included 147 patients (101 women (68.7%); mean age 75.8±10 years); 99 had centred SOA. As compared with patients with non-centred SOA, those with centred SOA were older (77.5±9 vs 72.4±11 years; p=0.004) with no difference in cardiometabolic disturbances or their accumulation. Multivariable analyses indicated that older age was independently associated with centred SOA (OR 1.06;95% CI 1.02 to 1.1; p=0.004), and cardiovascular diseases were less associated with this subtype (OR 0.27; 95% CI 0.089 to 0.824; p=0.02) than with the non-centred one.

Conclusion: Cardiometabolic risk factors were not more prevalent with primary centred than rotator cuff-related SOA. They may participate in the pathophysiology of both SOA subtypes through cartilage and tendon disruption.
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http://dx.doi.org/10.1136/rmdopen-2016-000429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5604608PMC
June 2017

Comparison of lateral and skyline fluoroscopic views for detection of prominent screws in distal radius fractures plating: results of an ultrasonographic study.

Arch Orthop Trauma Surg 2017 Oct 13;137(10):1357-1362. Epub 2017 Jul 13.

Orthopedics and Hand Surgery Department, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.

Introduction: Extensor tendon rupture is a recognized complication of volar plate fixation of distal radius fractures due to screws protruding past the dorsal cortex. The aim of this study was to compare the Skyline view with traditional lateral fluoroscopic views using ultrasonography as a reference standard in the postoperative assessment.

Materials And Methods: A monocentric prospective study was conducted to identify screws penetrating the dorsal cortex after volar plating of distal radius fractures.

Patients And Intervention: Intraoperative anteroposterior (AP) and lateral views were used for group A (28 patients). AP, lateral and skyline fluoroscopic views were used for Group B (40 patients). Prominent screws were changed.

Main Outcome Measurements: Ultrasound was done 6 months postoperatively to evaluate the number and length of prominent dorsal screws and any signs of extensor tenosynovitis.

Results: The number of prominent dorsal screws exceeding 1 mm was 14 in group A (14.9%), and 16 screws (11.8%) in group B (p = 0.487). Average length of prominent dorsal screw was 1.9 mm (range 1-2.1 mm) for group A and 2.4 mm (range 1.1-4.8 mm) for group B (p = 0.534). The number of patients with extensor tenosynovitis was 11 for group A and 12 for group B (p = 0.66).

Conclusions: The Skyline view does not provide sensitive and reliable detection of the dorsal screw penetration. Intraoperative ultrasound might be a better tool to detect screw prominence.

Level Of Evidence: III, case-control study.
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http://dx.doi.org/10.1007/s00402-017-2759-yDOI Listing
October 2017

The nuclear factor-erythroid 2-related factor/heme oxygenase-1 axis is critical for the inflammatory features of type 2 diabetes-associated osteoarthritis.

J Biol Chem 2017 09 6;292(35):14505-14515. Epub 2017 Jul 6.

From the Sorbonne University, UPMC University of Paris 06, Paris, France.

Epidemiological findings support the hypothesis that type 2 diabetes mellitus (T2DM) is a risk factor for osteoarthritis (OA). Moreover, OA cartilage from patients with T2DM exhibits a greater response to inflammatory stress, but the molecular mechanism is unclear. To investigate whether the antioxidant defense system participates in this response, we examined here the expression of nuclear factor-erythroid 2-related factor (Nrf-2), a master antioxidant transcription factor, and of heme oxygenase-1 (HO-1), one of its main target genes, in OA cartilage from T2DM and non-T2DM patients as well as in murine chondrocytes exposed to high glucose (HG). experiments indicated that Nrf-2 and HO-1 expression is reduced in T2DM non-T2DM OA cartilage (0.57-fold Nrf-2 and 0.34-fold HO-1), and prostaglandin E (PGE) release was increased in samples with low HO-1 expression. HG-exposed, IL-1β-stimulated chondrocytes had lower Nrf-2 levels , particularly in the nuclear fraction, than chondrocytes exposed to normal glucose (NG). Accordingly, HO-1 levels were also decreased (0.49-fold) in these cells. The HO-1 inducer cobalt protoporphyrin IX more efficiently attenuated PGE and IL-6 release in HG+IL-1β-treated cells than in NG+IL-1β-treated cells. Greater reductions in HO-1 expression and increase in PGE/IL-6 production were observed in HG+IL-1β-stimulated chondrocytes from Nrf-2 mice than in chondrocytes from wild-type mice. We conclude that the Nrf-2/HO-1 axis is a critical pathway in the hyperglucidic-mediated dysregulation of chondrocytes. Impairments in this antioxidant system may explain the greater inflammatory responsiveness of OA cartilage from T2DM patients and may inform treatments of such patients.
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http://dx.doi.org/10.1074/jbc.M117.802157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5582843PMC
September 2017

Finger reconstruction using induced membrane technique and ulnar pedicled forearm flap: a case report.

Arch Orthop Trauma Surg 2017 May 13;137(5):719-723. Epub 2017 Mar 13.

Orthopaedic, Trauma, and Hand Surgery, Saint Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.

Introduction: Injuries referred to as "rollover hands" are associated with multiple and complex lesions of the dorsal aspect of the hand. We present a case of a multitissular reconstruction following a severe injury of the dorsum of the fingers in a 45-year-old woman.

Materials And Methods: The bone loss reconstruction was performed in two stages using the Masquelet induced membrane technique. In the first stage, a cement spacer was inserted into the phalanx bone defects. For the second stage, the membrane induced by the foreign-body reaction was opened, the spacer was removed, and an autologous cancellous bone graft was inserted into the defects. The skin coverage was obtained using a reverse ulnar artery forearm pedicled flap. The digits were covered jointly. Three surgical procedures over the course of a 2-month period were required to desyndactylize the fingers and to defat the flap.

Results: At the 2-year follow-up examination, the patient exhibited good integration of their hand use in daily living. The esthetic result was deemed to be satisfactory. Definitive bone consolidation occurred 4 months after the second stage.

Conclusions: Rollover hands are typically a challenge for both the patient and the hand surgeon. The risk of septic complications, as well as the need for several stages of surgical reconstruction, makes the Masquelet technique particularly attractive for the treatment of phalanx bone defects consecutive to rollover injuries.
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http://dx.doi.org/10.1007/s00402-017-2666-2DOI Listing
May 2017

Guidelines on smoking management during the perioperative period.

Anaesth Crit Care Pain Med 2017 Jun 24;36(3):195-200. Epub 2017 Feb 24.

Pôle réanimations-anesthésie et Samu, CHU de Rouen, Normandy University, 76031 Rouen cedex, France. Electronic address:

Smoking is a public health problem of particular importance during the perioperative period, since it exposes patients scheduled for surgery to risk increases of 20% in hospital mortality and 40% in major postoperative complications. In addition, current smoking increases almost all specific surgical complications. The perioperative period offers a genuine opportunity for smoking cessation. The rate of preoperative smoking cessation can be increased significantly by offering behavior management and the prescription of a nicotine substitute before any scheduled surgical intervention. Preoperative smoking cessation should be routinely recommended independently of the timing of the intervention, even though the benefits increase in proportion with the length of cessation. All professionals of the care pathway (general practitioners, surgeons, anesthetists-intensivists, caregivers) must inform smokers of the positive effects of smoking cessation and offer them dedicated management and personalized follow-up. In children, cessation of parental smoking or removal of the child from environmental tobacco smoke as long before surgery as possible is indispensable.
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http://dx.doi.org/10.1016/j.accpm.2017.02.002DOI Listing
June 2017

Spontaneous bilateral quadriceps tendon rupture revealing a parathyroid carcinoma.

Joint Bone Spine 2018 01 20;85(1):131-132. Epub 2017 Jan 20.

Orthopeadic department, Saint-Antoine Hospital, 75012 Paris, France.

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http://dx.doi.org/10.1016/j.jbspin.2017.01.003DOI Listing
January 2018

Expression and function of visfatin (Nampt), an adipokine-enzyme involved in inflammatory pathways of osteoarthritis.

Arthritis Res Ther 2014 Jan 31;16(1):R38. Epub 2014 Jan 31.

Introduction: Visfatin is an adipokine that may be involved in intertissular joint communication in osteoarthritis (OA). With a homodimeric conformation, it exerts nicotinamide phosphoribosyltransferase (Nampt) enzymatic activity, essential for nicotinamide adenine dinucleotide biosynthesis. We examined the tissular origin and conformation of visfatin/Nampt in human OA joints and investigated the role of visfatin/Nampt in chondrocytes and osteoblasts by studying Nampt enzymatic activity.

Methods: Synovium, cartilage and subchondral bone from human OA joints were used for protein extraction or incubated for 24 hours in serum-free media (conditioned media), and synovial fluid was obtained from OA patients. Visfatin/Nampt expression in tissular extracts and conditioned media was evaluated by western blot and enzyme-linked immunosorbent assay (ELISA), respectively. Nampt activity was assessed in OA synovium by colorimetric assay. Primary cultures of murine chondrocytes and osteoblasts were stimulated with visfatin/Nampt and pretreated or not with APO866, a pharmacologic inhibitor of Nampt activity. The effect on cytokines, chemokines, growth factors and hypertrophic markers expression was examined by quantitative reverse transcriptase polymerase chain reaction and/or ELISA.

Results: In tissular explants, conditioned media and synovial fluid, visfatin/Nampt was found as a homodimer, corresponding to the enzymatically active conformation. All human OA joint tissues released visfatin/Nampt (synovium: 628 ± 106 ng/g tissue; subchondral bone: 195 ± 26 ng/g tissue; cartilage: 152 ± 46 ng/g tissue), with significantly higher level for synovium (P <0.0005). Nampt activity was identified ex vivo in synovium. In vitro, visfatin/Nampt significantly induced the expression of interleukin 6, keratinocyte chemoattractant and monocyte chemoattractant protein 1 in chondrocytes and osteoblasts. APO866 decreased the mRNA and protein levels of these pro-inflammatory cytokines in the two cell types (up to 94% and 63% inhibition, respectively). Levels of growth factors (vascular endothelial growth factor, transforming growth factor β) and hypertrophic genes were unchanged with treatment.

Conclusion: Visfatin/Nampt is released by all human OA tissues in a dimeric enzymatically active conformation and mostly by the synovium, which displays Nampt activity. The Nampt activity of visfatin is involved in chondrocyte and osteoblast activation, so targeting this enzymatic activity to disrupt joint tissue interactions may be novel in OA therapy.
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http://dx.doi.org/10.1186/ar4467DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3978827PMC
January 2014

The mini postero-postero-lateral mini incision in total hip arthroplasty.

Int Orthop 2013 Oct 22;37(10):1891-5. Epub 2013 Jun 22.

Department of Orthopaedics, Hôpital Saint Antoine , Paris, France,

Purpose: Mini invasive incisions in THA and femoral hip prostheses tend to minimise healing and recovery time. We have used a very posterior approach with technical modifications and precise skin landmarks to decrease surgical complexity, and we describe this experience here.

Methods: From 2010 to 2012, 140 patients aged 79 years (range 53-93 years) were operated upon by the same surgeon in a continuous series using the same minimally invasive skin incision and six different types of implants. The incision was very posterior in the hip allowing direct visualisation of the acetabulum in the hip flexion position and visualisation of the femoral shaft extremity in a leg flexion position.

Results: The mean operating time was 100 minutes (range 75-110 min). Estimated blood loss was 385 cc (20-585 cc). Twenty-six patients had blood transfusion. The mean hospital stay was 6.8 days (5-20 days) including the time waiting for a rehabilitation centre. No operative complications related to the technique were recorded. On the postoperative radiograph, the femoral stem was aligned with the femoral axis within 3° in all patients. The mean acetabular angle to the ground plane was 40° (35-48°). No patient had a leg length discrepancy of more than four millimetres. The mean skin incision length was seven centimetres (six to eight centimetres). All patients were seen at the clinic after six weeks and the data were unchanged at this time point.

Conclusion: The method and skin landmarks we describe appear to be a safe way to perform minimally invasive total hip replacement.
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http://dx.doi.org/10.1007/s00264-013-1970-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3779561PMC
October 2013

Balloon treatment of posterior shoulder dislocation with reverse Hill-Sachs injury: description of a new technique.

Int Orthop 2013 Jul 9;37(7):1291-5. Epub 2013 Apr 9.

Orthopedics, Hôpital Saint Antoine, Paris, France.

Purpose: Posterior shoulder dislocations are rare, and are usually the result of seizures. Anterior defects of the humeral head known as "reverse Hill-Sachs lesions" may increase the risk of recurrent dislocation and are difficult to treat. We developed a percutaneous technique for reduction of the dislocation or reduction of the anterior impaction fracture, using percutaneous balloon dilatation and cement fixation.

Methods: From 2009 to 2012, three patients aged 33, 72 and 75 years were admitted to our institution with a posterior shoulder dislocation showing an anterior "reverse Hill-Sachs" impaction fracture. One case was bilateral (four fractures). Patients were operated upon in the sitting position; the humeral head was stabilised by external fixator pins during balloon inflation. Reduction or filling of the defect was obtained in all cases. All patients were followed up and two patients (three fractures) were examined after one year by an independent observer. The clinical results were assessed using the Constant score and the RAND-36 physical components score. A computed tomography (CT) scan was obtained in all patients before and after the operation and at the latest follow-up.

Results: At three months postoperatively, all patients had resumed work or daily life activities with no limitation. The mean Constant score was 71 and RAND-36 score was 85.5. After one year, the mean Constant score was 73 and the RAND-36 score was 86.4 for the two patients who had sufficient follow-up. On the postoperative radiograph and CT scan, sphericity of the humeral head was restored, and the reverse Hill-Sachs impaction was filled or reduced in all cases. There was no recurrent dislocation.

Conclusion: Based on this small series, we believe that this technique should be added to our current armamentarium for posterior shoulder dislocations showing a deep impaction fracture of the humeral head that are at risk for recurrent dislocation.
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http://dx.doi.org/10.1007/s00264-013-1877-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3685657PMC
July 2013

New method for measuring acetabular component positioning with EOS imaging: feasibility study on dry bone.

Int Orthop 2012 Nov 5;36(11):2205-9. Epub 2012 Sep 5.

Department of Orthopaedic and Trauma Surgery, Saint Antoine Hospital, 184 rue du Faubourg Saint Antoine, 75571 Paris cedex 12, France.

Purpose: Malposition of the acetabular cup is the most common cause of total hip arthroplasty (THA) dislocation. The position of a total hip implant is usually analysed on computed tomography (CT) scan. We aim to prove it is possible to measure, with good accuracy, the position of an acetabular cup using the low-dose irradiation (EOS) imaging.

Material And Methods: We implanted an acetabular cup in a pelvic dry bone and measured cup anteversion and inclination with scanography. We performed 14 series of EOS acquisitions with different inclination, rotation and pelvic tilt, which were analysed by five observers. Two observers repeated angle measurements. We then calculated measurement inter- and intrareproducibility and accuracy.

Results: Using a confidence interval (CI) of 95 %, inter- and intra-observer reproducibility were ±1.6, and ±1.4°, respectively, for cup inclination; accuracy in comparison with CT was ±2.6°. Using a 95 % CI, inter- and intra-observer reproducibility for cup anteversion were ±2.5° and ±2.3°, respectively. Measurement accuracy compared with CT was ±3.9°.

Conclusion: EOS imaging system is superior to standard radiography in terms of measuring acetabular anteversion and inclination.
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http://dx.doi.org/10.1007/s00264-012-1650-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3479277PMC
November 2012

Measuring the Cobb angle with the iPhone in kyphoses: a reliability study.

Int Orthop 2012 Aug 1;36(8):1655-60. Epub 2012 Jun 1.

Orthopedics, Hôpital Saint Antoine, Paris, France.

Purpose: Smartphones have gained widespread use in the healthcare field to fulfill a variety of tasks. We developed a small iPhone application to take advantage of the built-in position sensor to measure angles in a variety of spinal deformities. We present a reliability study of this tool in measuring kyphotic angles.

Methods: Radiographs taken from 20 different patients' charts were presented to a panel of six operators at two different times. Radiographs were measured with the protractor and the iPhone application and statistical analysis was applied to measure intraclass correlation coefficients between both measurement methods, and to measure intra- and interobserver reliability

Results: The intraclass correlation coefficient calculated between methods (i.e. CobbMeter application on the iPhone versus standard method with the protractor) was 0.963 for all measures, indicating excellent correlation was obtained between the CobbMeter application and the standard method. The interobserver correlation coefficient was 0.965. The intraobserver ICC was 0.977, indicating excellent reproductibility of measurements at different times for all operators. The interobserver ICC between fellowship trained senior surgeons and general orthopaedic residents was 0.989. Consistently, the ICC for intraobserver and interobserver correlations was higher with the CobbMeter application than with the regular protractor method. This difference was not statistically significant.

Conclusion: Measuring kyphotic angles with the iPhone application appears to be a valid procedure and is in no way inferior to the standard way of measuring the Cobb angle in kyphotic deformities.
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http://dx.doi.org/10.1007/s00264-012-1579-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3535038PMC
August 2012

Crucial role of visfatin/pre-B cell colony-enhancing factor in matrix degradation and prostaglandin E2 synthesis in chondrocytes: possible influence on osteoarthritis.

Arthritis Rheum 2008 May;58(5):1399-409

UMR 7079, University Pierre and Marie Curie Paris VI, CNRS, Paris, France.

Objective: Prostaglandin E2 (PGE2) is one of the main catabolic factors involved in osteoarthritis (OA), and metalloproteinases (MMPs) are crucial for cartilage degradation. PGE2 synthesis under inflammatory conditions is catalyzed by cyclooxygenase 2 and microsomal PGE synthase 1 (mPGES-1), whereas NAD+-dependent 15-hydroxy-PG dehydrogenase (15-PGDH) is the key enzyme implicated in PGE2 catabolism. The present study was undertaken to investigate the contribution of visfatin, an adipose tissue-derived hormone, to the pathophysiology of OA, by examining its role in PGE2 synthesis and matrix degradation.

Methods: The synthesis of visfatin by human chondrocytes from OA patients, with and without stimulation with interleukin-1beta (IL-1beta) and the role of visfatin in PGE2 synthesis were analyzed by real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and immunoblotting. The effects of visfatin (1-10 microg/ml) on mPGES-1 and 15-PGDH synthesis, on the subsequent release of PGE2, and on MMP-3, MMP-13, ADAMTS-4, ADAMTS-5, and PG synthesis by primary immature mouse articular chondrocytes were examined by quantitative RT-PCR, immunoblotting, and enzyme-linked immunosorbent assay. Finally, small interfering RNA (siRNA) was used to assess the influence of visfatin on IL-1beta-induced release of PGE2 in immature mouse articular chondrocytes.

Results: Human OA chondrocytes produced visfatin, and visfatin synthesis was increased by IL-1beta treatment. Visfatin, like IL-1beta, triggered excessive release of PGE2, due to increased mPGES-1 synthesis and decreased 15-PGDH synthesis. Visfatin knockout with siRNA reduced IL-1beta-induced PGE2 overrelease. Visfatin triggered ADAMTS-4 and ADAMTS-5 expression and MMP-3 and MMP-13 synthesis and release, and reduced synthesis of high molecular weight PG by immature mouse articular chondrocytes.

Conclusion: The findings of this study indicate that visfatin has a catabolic function in cartilage and may have an important role in the pathophysiology of OA.
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http://dx.doi.org/10.1002/art.23431DOI Listing
May 2008

Arthroscopic stabilization of Neer type 2 fracture of the distal part of the clavicle.

Arthroscopy 2007 Jun 18;23(6):674.e1-4. Epub 2007 Jan 18.

Service de Chirurgie Orthopedique et Traumatologie, Hopital Saint Antoine, Faculte de Medecine Paris 6, Paris, France.

With regard to the anatomic basis of Neer type 2 fractures of the distal part of the clavicle, a clavicle fracture is associated with a coracoclavicular conoid ligament disruption. We describe an arthroscopic-assisted surgical procedure to stabilize the fracture and reconstruct the ligament. Surgery is performed with the patient in the beach-chair position. Through a 2-cm incision perpendicular to the direction of the fracture, we perform suturing around the fracture. During the arthroscopic procedure, the coracoid process is exposed by opening the rotator interval and the medial part of the capsule. The knee of the coracoid process should be exposed via an anterolateral portal for the arthroscope. Then, by use of an acromioclavicular joint stabilization device from Arthrex (Naples, FL), a hole is placed through the knee of the coracoid process. FiberTape suture (Arthrex) is passed around the clavicle and through the knee of the coracoid process. The intra-articular sutures are pulled out through the upper incision on top of the clavicle. Tightening of the 2 knots is performed at the same time. This arthroscopic-assisted surgery allows for total recovery of shoulder function, without the inconvenience of device migration or acromioclavicular joint lesions reported with other procedures.
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http://dx.doi.org/10.1016/j.arthro.2006.08.028DOI Listing
June 2007

Three-dimensional computed tomographic scan of the external third of the clavicle.

Arthroscopy 2007 Jan;23(1):29-33

Service de Chirurgie Orthopédique, Unité Membre Supérieur, Hôpital Saint Antoine-Université Paris 6, Paris, France.

Purpose: The aims of this radiologic study were to explore the anatomic aspect of the external third of the clavicle and to determine anatomic elements that can be useful for surgeons who perform surgery that involves this area.

Methods: Twenty patients with healthy acromioclavicular (AC) joints underwent computed tomographic (CT) scan for assessment of the lateral clavicle. Three-dimensional reconstruction of the AC joint and of the external third of the clavicle was performed. The axis of the external third was determined by CT scan reconstruction. Two-dimensional reconstructions were performed perpendicular to this axis; each involved 5 mm for exploration of the size of the 4 cortical bones and of the inner diameter of the clavicle.

Results: The average size of the external third before the anterior curve of the clavicle was 40 mm. The average inner diameter of the clavicle ranged from 8.24 to 4.7 mm when measured medially, but many differences were noted between patients. The upper cortical bone was thicker than 2 mm at an average of 17 mm from the AC joint. Three forms of the external third of the clavicle were identified: truncated (n = 6), conical (n = 4), and cylindrical (n = 10). The projection of the axis of the external third of the clavicle at the external side of the acromial bone ranged from 4.8 to 21 mm (average, 12.42 mm) at the backward anterior side of the acromial bone.

Conclusions: Our study shows the great variability of the anatomy of the external third of the clavicle.

Clinical Relevance: Anatomic data should be useful for surgeons who perform fixation or resection of the distal part of the clavicle.
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http://dx.doi.org/10.1016/j.arthro.2006.08.007DOI Listing
January 2007

Mini-open arthroscopically assisted Bristow-Latarjet procedure for the treatment of patients with anterior shoulder instability: a cadaver study.

Arthroscopy 2006 Oct;22(10):1113-8

Service de Chirurgie Orthopédique, Hôpital Saint Antoine Université Paris VII, Paris, France.

Purpose: The purpose of this study was to evaluate the arthroscopically assisted Bristow-Latarjet procedure. The aim was to use arthroscopic guidance to assist in positioning of the coracoid bone block onto the anterolateral aspect of the glenoid. The feasibility of this technique and its efficacy, reproducibility, and potential neurovascular complications were evaluated.

Methods: A minimally invasive technique was used to harvest the coracoid bone block and the attached coracobiceps tendon. A portal was created through the subscapularis muscle and, under arthroscopic guidance, the anterior aspect of the glenoid was cleaned and reamed before the bone block was placed. Cannulated screws (3.5 mm) were used to fix the vertically oriented bone block to the glenoid. The size of the bone block, its position on the glenoid, and its relation to the subscapularis tendon and the musculocutaneous and axillary nerves were recorded.

Results: In all 5 cadavers, the bone block was well positioned and was fixed to the anteroinferior part of the glenoid. No lesions of the cephalic vein or of the surrounding neurovasculature were observed.

Conclusions: This study demonstrated the safe and effective use of this arthroscopically assisted technique for correct positioning of the coracoid bone block at the anterolateral aspect of the glenoid in the cadaveric shoulder. Arthroscopy facilitated adequate reaming of the anterior glenoid and aided in optimal positioning of the bone block.

Clinical Relevance: This cadaveric study highlights the advantages offered by an arthroscopically assisted Bristow-Latarjet procedure, which optimizes positioning of the block and ensures adequate reaming of the anterior glenoid, thereby potentially reducing the risks of early nonunion and late arthritis--complications commonly associated with the classical Bristow-Latarjet technique.
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http://dx.doi.org/10.1016/j.arthro.2006.06.016DOI Listing
October 2006

Epithelioid solitary fibrous tumor in the ischioanal fossa.

Virchows Arch 2005 Jun 13;446(6):674-6. Epub 2005 May 13.

Department of Pathology, Hôpital St-Antoine, 184, rue du faubourg St-Antoine, 75012 Paris, France.

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http://dx.doi.org/10.1007/s00428-005-1255-xDOI Listing
June 2005

Cortical bone in the human femoral neck: three-dimensional appearance and porosity using synchrotron radiation.

J Bone Miner Res 2004 May 19;19(5):794-801. Epub 2004 Jan 19.

Laboratoire de Radiologie Expérimentale, Faculté de Médecine Lariboisière-Saint Louis, Paris, France.

Unlabelled: A high-resolution CT system using synchrotron radiation allowed visualization of the 3D cortical bone microarchitecture and measurement of intracortical porosity of femoral neck cortical bone specimens from 19 female cadavers imaged at 10.13-microm resolution. 3D reconstruction of specimens showed osteonal system arrangement. Mean porosity was 15.88%. This technique will provide insights into the mechanisms involved in osteoporotic hip fractures.

Introduction: The purpose of this study was to show that a high-resolution CT system using synchrotron radiation (SR) allows visualization of the 3D cortical bone microarchitecture of the human femoral neck and quantification of intracortical porosity.

Materials And Methods: Bone specimens from the inferior femoral neck were obtained from 19 female cadavers with no hip fracture (mean, 86.9 +/- 8.3 years). The specimens, consisting of embedded approximately 7 x 7 x 12-mm cortical bone parallelepipeds, were imaged using SR at 10.13-microm resolution. Commercial software was used to visualize both the 660 x 660 x 660-voxel volumes and the 2D axial slices through each volume. Qualitative examination of 2D axial slices focused on the appearance of the vessel canal system, presence of small bright zones (fully mineralized tissue) in the osseous matrix, and presence of cracks. A method was developed to automatically measure 3D intracortical porosity after separating pure bone from pores and cortical bone from trabecular bone.

Results And Conclusions: 3D reconstruction of the specimens showed the entire structure and arrangement of the osteonal systems, parallel to the axis of the femoral neck. Bright zones were seen in the outer cortex. No cracks were observed. Porosity values varied widely from 4.96% to 38.87% (mean, 15.88 +/- 9.87%). This study establishes that SR microtomography can be used to display the 3D bone microstructure of the human femoral neck cortex and to quantify intracortical porosity. This technique will provide insights into the mechanisms involved in cortical bone loss and osteoporotic hip fractures.
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http://dx.doi.org/10.1359/JBMR.040124DOI Listing
May 2004
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