Publications by authors named "Etienne Flamant"

7 Publications

  • Page 1 of 1

Increase in Use of Medial Ulnar Collateral Ligament Repair of the Elbow: A Large Database Analysis.

Arthrosc Sports Med Rehabil 2021 Apr 15;3(2):e527-e533. Epub 2021 Apr 15.

Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia, U.S.A.

Purpose: To assess the current national rate of medial ulnar collateral ligament (MUCL) repair of the elbow and delineate the patient demographics of those undergoing repair.

Methods: A retrospective review and analysis of a national private insurance database was conducted covering 2007-2017 using Pearl Diver technologies. All patients diagnosed with a MUCL injury and those who underwent repair were included using Clinical Modification and Current Procedural Terminology code 24345, referencing repair of the ulnar collateral ligament of the elbow with local tissue. The extracted data included patient age at time of procedure, sex, race, region, year of surgery, insurance type, hospital setting, and any associated diagnoses with 90 days of the repair procedure. Standard descriptive methods characterized our study sample to calculate frequency counts and percentages. Means with respective standard deviations and/or standard errors, and 95% confidence intervals were calculated and reported for continuous variables, whereas frequencies and percentages were reported for categorical variables. Pearson χ tests were used to determine differences between group proportion categorical variables. Significance was considered at a ≤ .05.

Results: From 2007 to 2014, MUCL injuries showed an upward trend in incidence per 100,000 from 4.59 to 7.19 (56% increase) within the database population. Accordingly, the incidence of MUCL repair rose from 0.016 to 0.49 (2962%). However, from 2015-2017 there was a drop in both categories, as injury incidence fell from 7.19 to 1.48 whereas repair rates dropped from 0.49 to 0.012. The ages undergoing repair show a significant peak in 15-24-year-olds. The incidence of MUCL repair was greatest in the West and South ( < .01). Male patients had a greater incidence of MUCL injury, and a greater incidence of MUCL repair per 100,000 persons compared to females ( < .01).

Conclusions: MUCL repair has emerged as a viable alternative to reconstruction in select indications. The impetus for this change may be to provide a quicker return to sport and fewer complications, largely due to recent improvements in surgical technique for MUCL repair. As anticipated, the incidence of MUCL repair had steadily increased in the United States from 2007 to 2014, with a subsequent relatively inexplicable decrease primarily in 2017, according to the database utilized in this study. The 15-24 year-old age group encompassing young athletes has the greatest incidence of repair by a significant margin.

Level Of Evidence: IV, Therapeutic Case Series.
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http://dx.doi.org/10.1016/j.asmr.2020.12.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8129461PMC
April 2021

Malnutrition in elective shoulder arthroplasty: a multi-institutional retrospective study of preoperative albumin and adverse outcomes.

J Shoulder Elbow Surg 2021 Apr 2. Epub 2021 Apr 2.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA. Electronic address:

Background: Malnutrition is associated with poor postoperative outcomes after knee, hip, and spine surgery. However, whether albumin labs should be part of the routine preoperative workup for shoulder arthroplasty remains understudied. This study investigated the role of preoperative albumin levels in predicting common postoperative adverse outcomes in patients undergoing shoulder arthroplasty.

Methods: All shoulder arthroplasty cases performed at 2 tertiary referral centers between July 2013 and May 2019 (institution 1) and between June 2007 and Feb 2020 (institution 2) were reviewed. A total of 421 primary and 71 revision elective shoulder arthroplasty cases had preoperative albumin levels recorded. Common demographic variables and relevant Elixhauser comorbidities were pulled. Outcomes gathered included extended (>3 days) postoperative inpatient length of stay (eLOS), 90-day readmission, and discharge to rehab or skilled nursing facility (SNF).

Results: The prevalence of malnutrition (albumin <3.5 g/dL) was higher in the revision group compared with the primary group (36.6% vs. 19.5%, P = .001). Reverse shoulder arthroplasty (P = .013) and increasing American Society of Anesthesiologists score (P = .016) were identified as independent risk factors for malnutrition in the primary group. In the revision group, liver disease was associated with malnutrition (P = .046). Malnourished primary shoulder arthroplasty patients had an increased incidence of eLOS (26.8% vs. 13.6%, P = .003) and discharge to rehab/SNF (18.3% vs. 10.3%, P = .045). On univariable analysis, low albumin had an odds ratio (OR) of 2.34 for eLOS (P = .004), which retained significance in a multivariable model including age, American Society of Anesthesiologists score, sex, and body mass index (OR 2.11, P = .03). On univariable analysis, low albumin had an OR of 1.94 for discharge to SNF/rehab (P = .048), but this did not reach significance in the multivariable model. Among revisions, malnourished patients had an increased incidence of eLOS (30.8% vs. 6.7%, P = .014) and discharge to rehab/SNF (26.9% vs. 4.4%, P = .010). In both the primary and revision groups, there was no difference in 90-day readmission rate between patients with low or normal albumin.

Conclusion: Malnutrition is more prevalent among revision shoulder arthroplasty patients compared with those undergoing a primary procedure. Primary shoulder arthroplasty patients with low preoperative albumin levels have an increased risk of eLOS and may have an increased need for postacute care. Low albumin was not associated with a risk of 90-day readmissions. Albumin level merits further investigation in large, prospective cohorts to clearly define its role in preoperative risk stratification.
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http://dx.doi.org/10.1016/j.jse.2021.03.143DOI Listing
April 2021

Humeral Shaft Fracture With Placement of an Intramedullary Nail Through an Unrecognized Sarcoma.

J Am Acad Orthop Surg Glob Res Rev 2021 02 19;5(2). Epub 2021 Feb 19.

From the Duke University School of Medicine, Durham, NC (Mr. Cullen, Mr. Flamant, and Mr. Ferlauto); The University of Houston Health Science Center, Houston, TX (Dr. Okwumabua); the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC (Dr. Brigman and Dr. Eward); and Duke Cancer Institute, Durham, NC (Dr. Brigman and Dr. Eward).

Case: A 72-year-old man underwent intramedullary nailing of a humeral diaphysis fracture with passage through an unrecognized pathologic fracture. Four months later, a biopsy of a soft-tissue mass in the arm revealed pleomorphic undifferentiated sarcoma. Only after local recurrence and forequarter amputation was the story of a pathologic fracture through undifferentiated pleomorphic sarcomas of bone clear. The patient developed metastatic disease and died after 2 years postoperatively.

Discussion: Orthopaedic surgeons should consider sarcoma when assessing patients with fractures of unknown etiology and an inappropriate mechanism because the placement of an intramedullary device through a sarcoma of bone has consequences.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00142DOI Listing
February 2021

Utility of postoperative hemoglobin testing following total shoulder arthroplasty.

JSES Int 2021 Jan 8;5(1):149-153. Epub 2020 Sep 8.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: Identifying areas of excess cost for shoulder arthroplasty patients can play a role in effective health care spending. The purpose of this study was to assess the utility of postoperative complete blood count (CBC) testing after total shoulder arthroplasty (TSA) and identify which patients benefit from routine CBC testing.

Methods: We performed a retrospective review of a cohort of patients who underwent primary TSA from January 2018 through January 2019. All patients in this cohort received tranexamic acid. Patient demographic characteristics and patient-specific risk factors such as American Society of Anesthesiologists score, Elixhauser index, body mass index, smoking status, and coagulopathy history were obtained. Perioperative values including length of surgery, preoperative and postoperative hemoglobin (Hgb) levels, and need for transfusion were also obtained.

Results: This study included 387 TSA patients in the final analysis. Comparison between the cohort requiring transfusion and the cohort undergoing no intervention revealed no statistically significant differences in age, sex, body mass index, American Society of Anesthesiologists score, or Elixhauser index. The group receiving transfusions was found to have significantly lower levels of preoperative Hgb (11.3 g/dL) and postoperative Hgb (8.1 g/dL) ( < .0001). Additionally, the percentages of patients with abnormal preoperative Hgb levels (<12 g/dL) (72.3%) and postoperative day 1 Hgb levels < 9 g/dL (81.8%) were significantly higher in the group receiving transfusions ( < .0001). A multivariate regression model identified an abnormal preoperative Hgb level (<12 g/dL), with an odds ratio of 3.8 (95% confidence interval, 1.5-6.2; < .001), and postoperative day 1 Hgb level < 9 g/dL, with an odds ratio of 3.3 (95% confidence interval, 0.4-6.1; < .03), as significant predictors of the risk of transfusion with a sensitivity of 64% and specificity of 96.2% with an area under the curve of 0.87.

Conclusion: Routine CBC testing may not be necessary for patients who receive tranexamic acid and have preoperative Hgb levels > 12 mg/dL and first postoperative Hgb levels > 9 mg/dL. This translates to potential health care cost savings and improves current evidence-based perioperative management in shoulder arthroplasty.
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http://dx.doi.org/10.1016/j.jseint.2020.07.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846688PMC
January 2021

A Comparative Oncology Drug Discovery Pipeline to Identify and Validate New Treatments for Osteosarcoma.

Cancers (Basel) 2020 Nov 11;12(11). Epub 2020 Nov 11.

Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.

Background: Osteosarcoma is a rare but aggressive bone cancer that occurs primarily in children. Like other rare cancers, treatment advances for osteosarcoma have stagnated, with little improvement in survival for the past several decades. Developing new treatments has been hampered by extensive genomic heterogeneity and limited access to patient samples to study the biology of this complex disease.

Methods: To overcome these barriers, we combined the power of comparative oncology with patient-derived models of cancer and high-throughput chemical screens in a cross-species drug discovery pipeline.

Results: Coupling in vitro high-throughput drug screens on low-passage and established cell lines with in vivo validation in patient-derived xenografts we identify the proteasome and CRM1 nuclear export pathways as therapeutic sensitivities in osteosarcoma, with dual inhibition of these pathways inducing synergistic cytotoxicity.

Conclusions: These collective efforts provide an experimental framework and set of new tools for osteosarcoma and other rare cancers to identify and study new therapeutic vulnerabilities.
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http://dx.doi.org/10.3390/cancers12113335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7696249PMC
November 2020

Intravenous tranexamic acid vs. topical thrombin in total shoulder arthroplasty: a comparative study.

J Shoulder Elbow Surg 2021 Feb 24;30(2):312-316. Epub 2020 Jun 24.

Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: Blood loss and transfusions have been highlighted as a significant predictor of postoperative morbidity. Tranexamic acid (TXA) has been shown to decrease blood loss and transfusion in shoulder arthroplasty. However, the utility of topical thrombin in total shoulder arthroplasty (TSA) is unknown. The purpose of this study was to assess the utility of topical thrombin in TSA and compare the effectiveness of topical thrombin to intravenous (IV) TXA.

Methods: An institutional database was used to query shoulder arthroplasty patients from January 2017 to July 2019. Patients undergoing TSA were identified with CPT (Current Procedural Terminology) code (23742). After excluding reverse shoulder arthroplasty, arthroplasty for fracture or revision, the study groups were stratified based on intervention with IV TXA, topical thrombin, or neither. Patient demographics, American Society of Anesthesiologists (ASA) class, baseline coagulopathy, preoperative and postoperative hemoglobin levels, operative time, transfusion, length of stay, and 90-day readmission for each treatment group was obtained.

Results: A total of 283 TSA cases were included for final analysis. There was no statistically significant difference in the baseline characteristics with age, body mass index, or ASA class. The postoperative hemoglobin level (mg/dL) was higher in the group that received either IV TXA or thrombin compared with no hemostatic agents (P = .001). Calculated blood loss in TSA was significantly higher in the group without hemostatic agents, 369.8 mL (standard deviation [SD] 59.5), compared with IV TXA or topical thrombin, 344.3 mL (SD 67.1) and 342.9 mL (SD 65.6) (P = .03). Operative time was highest in the group that received no hemostatic agents, 2.3 hours (SD 0.6) (P = .01). The transfusion rate for TSA treated with IV TXA or topical thrombin was equivalent (2.2%) but significantly lower than the no intervention group (12%) (P = .01). The odds ratio for transfusion with IV TXA was 0.16 (95% confidence interval [CI] 0.07-0.40, P = .001) and for topical thrombin, 0.1 (95% CI 0.02-0.42, P = .02).

Conclusion: Topical thrombin is an effective adjunct to reduce blood loss and transfusion risk after TSA and a reasonable intraoperative alternative for TXA for patients with contraindication to IV TXA.
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http://dx.doi.org/10.1016/j.jse.2020.05.039DOI Listing
February 2021

Defining the short-term effects of pharmacological 5'-AMP activated kinase modulators on mitochondrial polarization, morphology and heterogeneity.

PeerJ 2018 30;6:e5469. Epub 2018 Aug 30.

Department of Physiology, McGill University, Montreal, Canada.

Background: Under aerobic growth conditions, mitochondria are the major producers of cellular ATP and crucial for the proper performance of organs and tissues. This applies especially to cells with high energy demand, such as the renal proximal tubule epithelium. Mitochondrial dysfunction contributes to the pathology of human health conditions, including various kidney diseases. The improvement of mitochondrial function ameliorates some of these pathologies. This can potentially be achieved with pharmacological compounds. For example, long-term treatment with activators of 5'-AMP activated kinase (AMPK) enhances mitochondrial biogenesis. However, pharmacological damage control during acute cell injury requires that the short-term effects of these compounds and the impact on healthy cells are also understood. It was our objective to define the changes elicited by established modulators of AMPK activity in healthy renal proximal tubule cells.

Methods: Our work combines confocal microscopy with quantitative image analysis, 3D image reconstruction and Western blotting to provide novel insights into the biology of mitochondria. Specifically, we evaluated the effects of pharmacological AMPK modulators (compound C, AICAR, phenformin, resveratrol) on mitochondrial polarization, morphology and heterogeneity. Microscopic studies generated information at the single cell and subcellular levels. Our research focused on LLC-PK1 cells that are derived from the renal proximal tubule. Mitochondrial heterogeneity was also examined in MCF7 breast cancer cells.

Results: Pharmacological agents that affect AMPK activity in renal proximal tubule cells can alter mitochondrial organization and the electrochemical potential across the inner mitochondrial membrane. These changes were compound-specific. Short-term incubation with the AMPK inhibitor compound C caused mitochondrial hyperpolarization. This was accompanied by mitochondrial fragmentation. By contrast, AMPK activators AICAR, phenformin and resveratrol had little impact. We further show that the biological properties of mitochondria are determined by their subcellular location. Mitochondria at the cell periphery displayed higher MitoTracker/Tom70 values as compared to organelles located in the vicinity of the nucleus. This was not limited to renal proximal tubule cells, but also observed in MCF7 cells. Pharmacological AMPK modulators altered these location-dependent properties in a compound-specific fashion. While the region-dependent differences were enhanced with phenformin, they were ameliorated by resveratrol.

Discussion: We evaluated the rapid changes in mitochondrial characteristics that are induced by pharmacological AMPK modulators. Our research supports the concept that pharmacological agents that target AMPK can rearrange mitochondrial networks at the single cell level. Collectively, these insights are relevant to the development of proper strategies for the short-term adjustment of mitochondrial performance.
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http://dx.doi.org/10.7717/peerj.5469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6119600PMC
August 2018
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