Publications by authors named "Laurent Mathieu"

48 Publications

δ-Valerolactamic Quaternary Amino Acid Derivatives: Enantiodivergent Synthesis and Evidence for Stereodifferentiated β-Turn-Inducing Properties.

J Org Chem 2021 May 7. Epub 2021 May 7.

Institut des Molécules et Matériaux du Mans (IMMM) - UMR 6283 CNRS-Le Mans Université, Equipe Méthodologie et Synthèse Organique, F-72085 Le Mans Cedex 09, France.

Enantiopure () and () cyclic α,α-disubstituted amino acid derivatives displaying a δ-valerolactam side chain were prepared from a common isoxazolidine precursor. The ()-configured δ-valerolactam was converted into diastereoisomeric pseudopeptides to investigate its ability to induce secondary structures in peptidomimetics. Conformational studies of these pseudopeptides were carried out in the solid state (X-ray diffraction), in solution (NMR analyses), and (computer-aided conformational analysis), which demonstrated that such quaternary amino acids induce β-turn conformations stable enough to be retained in polar media (DMSO). Incorporation of this new type of α,α-disubstituted amino acid into a representative pseudopeptidic sequence by - then -elongation and -debenzylation is also described herein and could serve for the synthesis of various structured peptidomimetics.
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http://dx.doi.org/10.1021/acs.joc.1c00456DOI Listing
May 2021

Challenges of the induced-membrane technique in the reconstruction of traumatic tibial defect with limited resources : a cohort study.

Acta Orthop Belg 2020 Dec;86(4):606-613

This study sought foremost to evaluate the outcomes of applying the induced membrane technique (IMT) for tibia reconstruction within the context of a sub-Saharan Africa trauma center. Second, this study aimed to elucidate the conditions of IMT usage in a limited-resource setting. A retrospective study was performed among patients treated via IMT for posttraumatic tibial bone defects who had follow-up data available for at least 12 months. Eleven patients with a mean age of 36 years were included. All presented with an infected multi-tissue defect. The mean length of the tibia defect was 4.4 cm and the mean area of the soft-tissue loss was 32 cm . Pedicled flap coverage was required in all cases. At the mean follow-up time of 15 months bone union was achieved in nine of 11 cases, after additional inter-tibiofibular grafting was performed in four cases. Infection recurrence was noted in five of 11 cases. Most patients presented medium-quality soft-tissue coverage and suboptimal function. IMT may represent a valuable option for tibia reconstruction with limited surgical resources in cases where appropriate infection control and stable soft-tissue coverage can be ensured.
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December 2020

Single versus double tendon transfer for foot drop due to post-traumatic common fibular nerve palsy.

Eur J Trauma Emerg Surg 2021 Jan 21. Epub 2021 Jan 21.

Brachial Plexus and Peripheral Nerve Surgery Unit, Mont-Louis Private Hospital, 8 rue de la Folie-Regnault, 75011, Paris, France.

Purpose: To compare functional outcomes of single versus double tendon transfer for foot drop correction and toe drop prevention in posttraumatic common fibular nerve palsy.

Methods: A retrospective study was conducted on data from patients with posttraumatic common fibular nerve palsy treated by tendon transfer between 2001 and 2018. In cases of single tendon transfer (STT) the tibialis posterior (TP) tendon was transferred anteriorly through the interosseous membrane to a new insertion on the lateral cuneiform. In cases of double tendon transfer (DTT), the same TP tendon transfer was combined with a transfer of the flexor digitorum longus to the extensor digitorum longus and extensor hallucis longus tendons. Functional assessment was based on the Carayon score to evaluate foot drop correction and on the Yeganeh score to evaluate toe drop prevention.

Results: A total of 27 patients were included: 13 in the STT group and 14 in the DTT group. Functional results were comparable between groups in terms of reduction of foot drop, active range of ankle motion and Carayon score. Prevention of toe drop, active toe extension and Yeganeh score were significantly greater in the DTT group, however, active toe extension of was only restored in only 8 cases in the DTT group.

Conclusions: Double transfer of TP and FDL tendons is a reliable method to restore balanced ankle dorsiflexion and prevent toe drop. However, recovery of active toe extension was inconsistent and Carayon scores were not superior to those obtained with a single TP tendon transfer.
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http://dx.doi.org/10.1007/s00068-021-01602-6DOI Listing
January 2021

Re: "High prevalence of heterotopic ossification in critically ill patients with severe COVID-19" by Stoira et al.

Clin Microbiol Infect 2021 Jan 15. Epub 2021 Jan 15.

Department of Physical Medicine and Rehabilitation, CIC 1429, Raymond Poincaré Hospital, APHP, Garches, France; END:ICAP U1179 INSERM, University of Versailles Saint Quentin en Yvelines, UFR Simone Veil-Santé, Montigny le Bretonneux, France.

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http://dx.doi.org/10.1016/j.cmi.2020.12.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7810024PMC
January 2021

Torture-induced hand electrical injury: A case report.

J Forensic Leg Med 2021 Jan 21;77:102085. Epub 2020 Nov 21.

Department of Orthopedic, trauma and reconstructive surgery, Percy Military Hospital, Clamart, France; Department of surgery, French Military Health Service Academy, Ecole du Val-de-Grâce, 1 place Alphone Laveran, 75005, Paris, France. Electronic address:

The authors report an unusual case of hand electrical injury related to torture in a war refugee. The patient was referred for the reconstruction of bilateral hand function several years after being tortured. He presented with severe hand contractures combined with motor and sensory loss. After nonoptimal treatment in the acute period, the reconstruction options were limited by the delayed management. This unique clinical presentation can be explained by repetition of prolonged electrical shocks using a low-voltage current.
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http://dx.doi.org/10.1016/j.jflm.2020.102085DOI Listing
January 2021

Induced membrane technique: a critical literature analysis and proposal for a failure classification scheme.

Eur J Trauma Emerg Surg 2020 Nov 23. Epub 2020 Nov 23.

Department of Orthopedic, Trauma and Hand Surgery, Saint-Antoine Hospital, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France.

The reconstruction of long-bone segmental defects remains challenging, with the three common methods of treatment being bone transport, vascularized bone transfer, and the induced membrane technique (IMT). Because of its simplicity, replicability, and reliability, usage of IMT has spread all over the world in the last decade, with more than 300 papers published in the PubMed literature database on this subject so far. Most of the clinical studies have reported high rates of bone union, yet some also include more controversial results with frequent complications and revision surgeries. At the same time, various experimental research efforts have been designed to understand and improve the biological properties of the induced membrane. This literature review aims to provide an overview of IMT clinical results in terms of bone union and complications and to compare them with those of other reconstructive procedures. In light of our findings, we then propose an original classification scheme of IMT failures distinguishing between preventable and nonpreventable failures.
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http://dx.doi.org/10.1007/s00068-020-01540-9DOI Listing
November 2020

Extremity soft tissue coverage in the combat zone: use of pedicled flap transfers by the deployed orthopedic surgeon.

Mil Med Res 2020 10 24;7(1):51. Epub 2020 Oct 24.

Department of Surgery, French Military Health Service Academy, Ecole du Val-de-Grâce, 75005, Paris, France.

Background: In theaters of operation, military orthopedic surgeons have to deal with complex open extremity injuries and perform soft-tissue reconstruction on local patients who cannot be evacuated. Our objective was to evaluate the outcomes and discuss practical issues regarding the use of pedicled flap transfers performed in the combat zone on local national patients.

Methods: A retrospective study was conducted on data from patients treated by a single orthopedic surgeon during four tours in Chad, Afghanistan and Mali between 2010 and 2017. All pedicled flap transfers performed on extremity soft-tissue defects were included, and two groups were analyzed: combat-related injuries (CRIs) and non-combat related injuries (NCRIs).

Results: Forty-one patients with a mean age of 25.6 years were included. In total, 46 open injuries required flap coverage: 19 CRIs and 27 NCRIs. Twenty of these injuries were infected. The mean number of prior debridements was significantly higher in the CRIs group. Overall, 63 pedicled flap transfers were carried out: 15 muscle flaps, 35 local fasciocutaneous flaps and 13 distant fasciocutaneous flaps. The flap types used did not differ for CRIs or NCRIs. Complications included one flap failure, one partial flap necrosis and six deep infections. At the mean follow-up time of 71 days, limb salvage had been successful in 38 of the 41 cases. There were no significant differences between CRIs and NCRIs in terms of endpoint assessment.

Conclusions: Satisfying results can be achieved by simple pedicled flaps performed by orthopedic surgeons deployed in forward surgical units. Most complications were related to failure of bone infection treatment. The teaching of such basic reconstructive procedures should be part of the training for any military orthopedic surgeon.

Trial Registration: Retrospectively registered on January 2019 (n°2019-090 1-001).
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http://dx.doi.org/10.1186/s40779-020-00281-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585288PMC
October 2020

Application of the Masquelet technique in austere environments: experience from a French forward surgical unit deployed in Chad.

Eur J Trauma Emerg Surg 2020 Aug 28. Epub 2020 Aug 28.

Clinic of Orthopedics, Traumatology and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, 92140, Clamart, France.

Purpose: We sought to evaluate the results of the Masquelet-induced membrane technique (IMT) for long bone defect reconstruction within the limited-resource setting of a French forward surgical unit deployed in Chad.

Methods: A prospective and observational study was conducted in all patients with a traumatic segmental bone defect in any anatomical location treated by IMT from November 2015 to December 2019. Although IMT was applied by various orthopedic surgeons with variable expertise, all followed the same surgical protocol. Endpoint assessment was performed 12 months after IMT application.

Results: Sixteen patients with a mean age of 32.7 years were included in the study. Bone defects were located on the tibia (n = 8), the femur (n = 6) or the radius (n = 2). Thirteen bone defects were infected. After debridement, the mean bone defect length was 4.3 cm. External fixation of the tibia and femur was predominant in both stages. Bone union was achieved in only 8 of the 16 cases at a mean time of 7.6 months. All failures were related to persistent infection or insufficient fixation stability in the second stage.

Conclusions: This series is the first to report IMT use in a forward surgical unit. Despite frequent complications, local patients can benefit from this procedure, which is the only available method for bone reconstruction in areas with limited medical resources. A rigorous technical completion at both stages is crucial to limit septic or mechanical failures.
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http://dx.doi.org/10.1007/s00068-020-01471-5DOI Listing
August 2020

Repeated Induced-Membrane Technique Failure without Infection: A Series of Three Consecutive Procedures Performed for a Single Femur Defect.

Case Rep Orthop 2020 7;2020:8892226. Epub 2020 Aug 7.

Military Biomedical Research Institute (IRBA), 1 Place Général Valérie André, 91220 Brétigny-sur-Orge, France.

A 40-year-old male was treated using the induced-membrane technique (IMT) for a noninfected, 9 cm long femoral bone defect complicating a lengthening procedure. The interesting case feature lies in the three consecutive IMT procedures that were necessary to achieve complete bone repair in this unusual clinical situation. The first procedure failed because of the lack of graft revascularization likely related to an induced-membrane (IM) alteration demonstrated by histological observations. The second IMT procedure led to partial graft integration interrupted by the elongation nail breakage. At last, the third procedure fully succeeded after nail exchange and iterative iliac bone grafting. Complete bone union was achieved with a poor functional recovery one year after the last procedure and four years following the first cement spacer implantation. By means of clinical and histological observations, we demonstrated that the first and the second IMT failures had two distinct origins, namely, biological and mechanical causes, respectively. Although simple, a successful IMT procedure is not so easy to complete.
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http://dx.doi.org/10.1155/2020/8892226DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429766PMC
August 2020

Hindfoot blast injuries caused by improvised explosive devices: long-term functional assessment in French military personnel.

Int Orthop 2021 03 8;45(3):751-757. Epub 2020 Aug 8.

Department of Orthopedics, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France.

Purpose: The chosen treatment and long-term evaluation of hindfoot blast injuries are not well-represented in the literature. The first objective of this retrospective study was to evaluate functional outcomes in French service personnel who had sustained such injuries caused by improvised explosive devices. The second objective was to compare the results for patients who had amputations with those who did not. The hypothesis was that amputee recovered better function.

Methods: Long-term functional evaluations were carried out using the American Orthopaedic Foot and Ankle Society scale (AOFAS), the Foot and Ankle Ability Measure (FAAM), and the Short Form 12 health survey (SF-12).

Results: Eight servicemen with ten hindfoot blast injuries were reviewed at a mean follow-up time of seven years. Primary management was always conservative although half of the patients required late amputation for chronic pain. The patients who underwent amputation reported significantly lower levels of pain than those who did not have an amputation, with higher FAAM and SF-12 scores.

Conclusion: In this series, long-term functional results appear better in the amputated group.
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http://dx.doi.org/10.1007/s00264-020-04766-9DOI Listing
March 2021

Induced membrane technique with sequential internal fixation: use of a reinforced spacer for reconstruction of infected bone defects.

Int Orthop 2020 09 21;44(9):1647-1653. Epub 2020 Jul 21.

Clinic of Orthopedics, Trauma and Hand Surgery, Saint-Antoine Hospital, 184 rue du Faubourg Saint-Antoine, 75012, Paris, France.

Purpose: To evaluate a novel sequential internal fixation strategy using a reinforced spacer for infected bone defect reconstruction by the induced membrane technique (IMT).

Methods: A retrospective case study was performed among patients treated for infected bone defects by applying this strategy. Following radical debridement, temporary stabilization was provided by a massive cement spacer combined with minimal intramedullary fixation during step 1. Definitive internal fixation was performed together with bone grafting at step 2.

Results: Eight patients with a mean age of 58 years were reviewed. The mean bone defect length was 8.8 cm. The spacer armature mostly consisted of elastic nails and Steinmann pins. Iterative debridement was required in one case after step 1. The mean interval between steps was 12 weeks. Definitive internal fixation was performed by intramedullary nailing (n = 4) or plating (n = 4). At a mean follow-up of 21 months, bone union was achieved in seven cases without additional bone grafting or infection recurrence.

Conclusions: Sequential internal fixation using a reinforced cement spacer seems to be a valuable option for avoiding external fixation between IMT steps and limiting the recurrence of infection.
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http://dx.doi.org/10.1007/s00264-020-04735-2DOI Listing
September 2020

Soft tissue reconstruction in the leg by orthopedic surgeons: Practices at an African trauma center.

Orthop Traumatol Surg Res 2020 Sep 10;106(5):825-829. Epub 2020 Jun 10.

French Military Health Service Academy, École du Val-de-Grâce, Paris, France; Department of orthopedics and traumatology, Hôpital Principal, Dakar, Sénégal.

Introduction: Soft-tissue coverage is a crucial step when treating open tibial fractures, which is often performed by orthopedic surgeons in a low resource setting. The objective of this study was to analyze the use of non-microsurgical flaps to treat such injuries in a West African trauma center.

Hypothesis: Pedicled flaps are reliable procedures that can be used by any orthopedic surgeon for soft-tissue coverage in the leg.

Methods: A retrospective study was conducted including patients treated between 2007 and 2011 for open tibial fractures or posttraumatic sequelae requiring flap coverage. Early flap necrosis and skin viability at the last follow-up were evaluated.

Results: Fifty-five patients with mean age 34 years were included. They had 57 soft-tissue defects requiring flap reconstruction, 36 of which were infected. In total, 62 pedicled flaps were performed: 12 muscular flaps and 50 fasciocutaneous flaps, including 40 rotational flaps and 10 island flaps. The short-term result was successful in 55 flaps (89%). Seven flaps had partial or complete necrosis, including three soleus flaps and three lateral supramalleolar rotational flaps. At the average follow-up of 9 months, skin viability was inferior in the posttraumatic sequelae group and seemed to be altered by primary bone infection.

Conclusion: Soft-tissue coverage in the leg can be reliably achieved by orthopedic surgeons using simple and robust flaps that do not require pedicle dissection. Surgeon training in basic flap surgery is essential and still inadequate in emerging countries.

Level Of Evidence: IV, Retrospective study.
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http://dx.doi.org/10.1016/j.otsr.2020.03.021DOI Listing
September 2020

Bone reconstruction by the induced membrane technique. What differences between conventional and ballistic trauma?

Orthop Traumatol Surg Res 2020 Sep 4;106(5):797-801. Epub 2020 May 4.

Service de chirurgie orthopédique, traumatologie et chirurgie réparatrice des membres, hôpital d'Instruction des Armées Percy, 101, avenue Henri Barbusse, 92140 Clamart, France; Chaire de chirurgie appliquée aux armées, École du Val-de-Grâce, 1, place Alphonse Laveran, 75005 Paris, France. Electronic address:

Background: The induced membrane technique (IMT) has been widely evaluated for reconstruction of post-traumatic bone defects. However, no specific evaluation was conducted in ballistic injuries. The objective of the present study was to compare IMT in conventional trauma (CT) versus ballistic trauma (BT) managed in a military trauma center.

Methods: A retrospective study was conducted between 2009 and 2018 in patients treated by IMT for post-traumatic bone defects, whatever the defect location. Endpoints comprised bone union, residual infection, additional bone grafting and lower-limb amputation.

Results: Thirty-six patients were included: 24 in the CT and 12 in the BT group. Demographics and injury pattern were similar in both groups, with open fracture and infected lesions predominating. The only significant difference was that tibial bone defects were larger in the BT group. Operative parameters and results were also similar. At a mean 24 months' follow-up, bone union rate was 83% in both groups, without significant differences in residual infection, complementary grafting or late amputation.

Conclusion: IMT is appropriate to bone reconstruction in the aftermath of ballistic trauma, with similar results to those obtained in conventional trauma.

Level Of Evidence: IV, retrospective study.
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http://dx.doi.org/10.1016/j.otsr.2019.10.026DOI Listing
September 2020

Towards Understanding Therapeutic Failures in Masquelet Surgery: First Evidence that Defective Induced Membrane Properties are Associated with Clinical Failures.

J Clin Med 2020 Feb 6;9(2). Epub 2020 Feb 6.

French Military Biomedical Research Institute (IRBA), BP73, 91220 Brétigny-sur-Orge, France.

The two-stage Masquelet induced-membrane technique (IMT) consists of cement spacer-driven membrane induction followed by an autologous cancellous bone implantation in this membrane to promote large bone defect repairs. For the first time, this study aims at correlating IMT failures with physiological alterations of the induced membrane (IM) in patients. For this purpose, we compared various histological, immunohistochemical and gene expression parameters obtained from IM collected in patients categorized lately as successfully (Responders; = 8) or unsuccessfully (Non-responders; = 3) treated with the Masquelet technique (6 month clinical and radiologic post-surgery follow-up). While angiogenesis or macrophage distribution pattern remained unmodified in non-responder IM as compared to responder IM, we evidenced an absence of mesenchymal stem cells and reduced density of fibroblast-like cells in non-responder IM. Furthermore, non-responder IM exhibited altered extracellular matrix (ECM) remodeling parameters such as a lower expression ratio of metalloproteinase-9 (MMP-9)/tissue inhibitor of metalloproteinases (TIMP-1) mRNA as well as an important collagen overexpression as shown by picrosirius red staining. In summary, this study is the first to report evidence that IMT failure can be related to defective IM properties while underlining the importance of ECM remodeling parameters, particularly the MMP-9/TIMP-1 gene expression ratio, as early predictive biomarkers of the IMT outcome regardless of the type of bone, fracture or patient characteristics.
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http://dx.doi.org/10.3390/jcm9020450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7073843PMC
February 2020

Management of Sciatic Nerve Defects: Lessons Learned and Proposal for a New Strategy.

Ann Plast Surg 2020 05;84(5):559-564

Mont-Louis Private Hospital, Paris, France.

Management of sciatic nerve injuries can be difficult for surgeons without a special interest in nerve surgery as they would only treat a handful of such cases for many years. Sciatic nerve defects pose the greatest repair challenges, with nerve grafting producing mixed results because of the large size of the nerve in both diameter and length. This article first presents the peculiarities of sciatic nerve defects management, based on the authors experience and a literature review. Various issues are dealt with: When to operate depending on the injury mechanism? What are the results of nerve autografting and allografting? On which component should the repair focus in very large defects? Subsequently, alternatives to conventional nerve grafting are proposed. The authors stress the usefulness of direct nerve suture with knee flexion at 90 degrees, which permits bridging of gaps as much as 8 cm in length. For larger defects, other procedures should be considered: long vascularized nerve grafting in complete lesions, short grafting with knee flexed, or tendon transfers in partial lesions.
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http://dx.doi.org/10.1097/SAP.0000000000002233DOI Listing
May 2020

Direct Suturing of Sciatic Nerve Defects in High-degree Knee Flexion: An Experimental Study.

World Neurosurg 2020 Jan 10;133:e288-e292. Epub 2019 Sep 10.

Clinic of Orthopedic, Trauma, and Reconstructive Surgery, Percy Military Hospital, Clamart, France; French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France. Electronic address:

Objective: We sought to elucidate the conditions of direct suturing of sciatic nerve defects in high-degree knee flexion. We aimed to establish a correlation among the defect length, defect location, degree of knee flexion, and eventual need for hip immobilization in extension.

Methods: We performed an experimental study by completing bilateral dissection of the sciatic nerve in 6 cadavers. Three groups of lesions were identified: at the buttock (BG), in the thigh (TG), and in the popliteal fossa (PG). For each defect, a direct, tensionless suture was performed with minimal knee flexion. Next, the hip was progressively flexed until rupture. The nerve defect length correlated with the degree of knee flexion and hip extension required to perform and protect the installed sutures.

Results: A 30° knee flexion allowed for direct suturing of defects >2 cm in the 3 groups. The largest suturable nerve defects measured 7 cm in the TG and PG and 6 cm in the BG. When considering the same-size defects, the required knee flexion tended to be significantly greater in the BG. A bowstringing effect was noted at the buttock and popliteal levels. Hip flexion placed tension on the nerve suture at all locations.

Conclusions: The middle third of the thigh was the most compliant level, because the largest defects will be suturable without a visible bowstringing effect. Hip immobilization should be considered as soon as the defect has exceeded 2 cm, regardless of the location.
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http://dx.doi.org/10.1016/j.wneu.2019.08.258DOI Listing
January 2020

Management of Gustilo type IIIB open tibial shaft fractures with limited resources: experience from an African trauma center.

Eur J Trauma Emerg Surg 2021 Feb 3;47(1):217-223. Epub 2019 Sep 3.

French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France.

Purpose: We sought to evaluate the management of Gustilo type IIIB open tibia diaphyseal fractures in an African trauma center with respect to soft tissue defect management and bone union achievement. Functional outcome assessment was the secondary objective.

Methods: A retrospective review was conducted including patients treated for open tibia fractures requiring flap coverage between 2007 and 2011. As plastic surgeons were lacking in availability, all procedures were performed by orthopedic surgeons trained in completing nonmicrosurgical flap transfers.

Results: Twenty-seven patients with a mean age of 36 years were included. Although the mean time to debridement was 11 h, early infection occurred in 16 (59%) patients. The mean time to flap coverage was 27 days. Among the 29 primary local flap transfers performed, only 4 failed. Secondary amputation was required in one patient after flap failure. Bone reconstruction procedures were required in nine patients and were performed after a mean period of 97 days. At the mean follow-up time of 13 months, 23 (88%) of the 26 remaining fractures had united. There were three septic nonunions and two cases of chronic osteomyelitis. Functional result was negatively influenced by the soft tissue defect area and low-quality flap coverage.

Conclusions: To our knowledge, this is the first series reporting flap reconstructions performed by orthopedic surgeons for Gustilo type IIIB tibia fractures in an African hospital. Local pedicled flap transfers permitted the achievement of soft tissue coverage and bone union in most cases. Subsequent bone grafting was required in one-third of the cases.
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http://dx.doi.org/10.1007/s00068-019-01223-0DOI Listing
February 2021

Masquelet technique for open tibia fractures in a military setting.

Eur J Trauma Emerg Surg 2020 Oct 26;46(5):1099-1105. Epub 2019 Aug 26.

Clinic of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 Avenue Henri Barbusse, 92140, Clamart, France.

Purpose: The induced membrane technique (IMT) is a two-stage procedure dedicated to reconstruction of bone defects of the limbs. The objective of this report was to evaluate employment of the IMT for the treatment of open tibia fractures managed in a military trauma center treating both wartime and peacetime injuries.

Methods: A retrospective study was performed among the patients treated via IMT for tibial bone defects related to open fractures between 2009 and 2018. The outcomes recorded included bone union, residual infection, amputation and lower limb function.

Results: During this period, 15 patients with a mean age of 39 years were included for the treatment of Gustilo II (2 cases) or Gustilo IIIB (13 cases) injuries. A mean number of 2.9 debridements were required before stage 1. Flap coverage was associated in 14 cases. The mean interval between stages was 22 weeks. Five patients were re-operated on after stage 1 due to persistent infection. The mean follow-up was 33 months. Bone union was achieved in 13 of the 15 cases (87%) at a mean time of 10.1 months. However, seven additional bone healing procedures were required, including six inter-tibiofibular grafting. Only one late septic recurrence was found. Most patients returned to work in sedentary jobs.

Conclusions: This series is the first to report IMT use in a military setting. The prior eradication of infection constitutes a major challenge in tibial bone defects, especially in high-energy, multi-tissue injuries. An inter-tibiofibular bone reconstruction approach is required when external fixation is chosen.
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http://dx.doi.org/10.1007/s00068-019-01217-yDOI Listing
October 2020

Sniper-induced sciatic nerve injury.

BMJ Mil Health 2020 Jun 29;166(3):210. Epub 2019 Jul 29.

Reconstructive Surgery Project, Médecins Sans Frontières, Amman, Jordan.

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http://dx.doi.org/10.1136/jramc-2019-001269DOI Listing
June 2020

Missile Injury of the Sciatic Nerve: Observational Study Supporting Early Exploration and Direct Suture With Flexed Knee.

Mil Med 2019 12;184(11-12):e937-e944

Mont-Louis Private Hospital, 8 rue de la Folie-Regnault 75011 Paris, France.

Missile injuries of the sciatic nerve are frequently encountered in modern violent conflicts. Gunshot and fragment wounds may cause large nerve defects, for which management is challenging. The great size of the sciatic nerve, in both diameter and length, explains the poor results of nerve repair using autografts or allografts. To address this issue, we used a simple technique consisting of a direct suture of the sciatic nerve combined with knee flexion for 6 weeks. Despite a published series showing that this procedure gives better results than sciatic nerve grafting, it remains unknown or underutilized. The purpose of this cases study is to highlight the efficiency of direct sciatic nerve coaptation with knee flexed through three cases with missile injuries at various levels. At the follow-up of two years, all patients were pain free with a protective sensory in the sole and M3+ or M4 gastrocnemius muscles, regardless of the injury level. Recovery was also satisfying in the fibular portion, except for the very proximal lesion. No significant knee stiffness was noticed, including in a case suffering from an associated distal femur fracture. Key points to enhance functional recovery are early nerve repair (as soon as definitive bone fixation and stable soft-tissue coverage are achieved) and careful patient selection.
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http://dx.doi.org/10.1093/milmed/usz087DOI Listing
December 2019

Risk factors and failures in the management of limb injuries in combat casualties.

Int Orthop 2019 12 11;43(12):2671-2680. Epub 2019 Apr 11.

Department of Orthopedic, Traumatology and Reconstructive Surgery, PERCY Military Teaching Hospital, 101 Avenue Henri Barbusse, 92141, Clamart, France.

Introduction: Treatment of war wounds is based on a sequential surgical strategy, which frequently faces therapeutic failures, which then burden the final functional result. The aim of this study was to identify risk factors of failure of the different treatments to prevent the therapeutic failure.

Methods: A monocentric case-control study was done on French war-wounded soldiers treated for an open fracture caused by an invasive war weapon. The primary end point was the treatment failure three months after the injury. The risk factors of failure studied were the traumatic mechanism, the general and local lesional assessment, and the surgery performed.

Results: Between January 1, 2004 and December 31, 2016, 57 soldiers were included, with an average follow-up of 3.42 years. On 81 limb segments studied, the most injured segment was the leg (37.0%). A vital or urgent surgery requirement (OR = 1.56; p = 0.02) and bone loss substance (OR = 5.45; CI95% = 1.54-20.09) were risk factors of failure for limb salvage treatment. Improvised explosive device traumatic mechanism (OR = 1.56; p = 0.02) and the persistence of surgical site contamination after two debridement procedures (OR = 1.20; p = 0.04) were risk factors of failure for amputation procedures.

Conclusions: Two main risk factors of treatment failure are highlighted: those in relation to traumatic mechanisms and general lesional assessment and those in relation to surgical site conditions. There is no over risk of failure in relation to surgical procedure and treatment.
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http://dx.doi.org/10.1007/s00264-019-04329-7DOI Listing
December 2019

Input of a Multi-Disciplinary Meeting in the Treatment of Osteoarticular Infections in French War Casualties.

Mil Med 2019 05;184(5-6):e359-e364

Department of Orthopedic, Traumatology and Reconstructive Surgery and Trauma, PERCY Military Teaching Hospital, 101 Avenue Henri Barbusse, Clamart, France.

Introduction: Extremity war-wounds present an elevated risk of infection and compromise reconstructive procedures. In a French military hospital, a multi-disciplinary meeting (MDM) was created to standardize the care given to soldiers with osteoarticular infection. The aim of this study was to evaluate the usefulness of MDM decisions.

Methods: An observational case study was performed including the French wounded at war treated for an osteoarticular infection between 2004 and 2016. They were separated into two groups according to their time of management: before (group A) or after (group B) the MDM creation in September 2010. Various operative and bacteriological parameters were analyzed retrospectively. A questionnaire was created to evaluate healthcare professionals' satisfaction toward the usefulness of the MDM on their practice.

Results: During the study period, 38 patients were included: 19 in group A and 19 in group B. Initial tests found an infection with one pathogen in 15 patients, an infection with 2 pathogens in 11 patients, and an infection with 3 or more pathogens in 12 patients. Enterobacter cloacae was the most common pathogen. Pseudomonas aeruginosa and Escherichia coli were also frequent. The mean number of samples taken to conduct the bacteriological tests per operating session was significantly higher for group B than for group A. Twelve of the 14 questioned healthcare professionals believed the MDM was very useful in their patient management.

Conclusion: The MDM seems to have had a beneficial impact on orthopedic surgeon practices. A significant increase of the number of samples taken was the most obvious sign that the French recommended practices for osteoarticular infections were followed since the creation of MDM.
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http://dx.doi.org/10.1093/milmed/usy369DOI Listing
May 2019

Sequential management of tibial fractures using a temporary unicortical external fixator.

SICOT J 2018 7;4:39. Epub 2018 Sep 7.

Department of Orthopedic Surgery, Traumatology and Reconstructive Surgery, Percy Military Hospital, Clamart, France - Department of Surgery, French Military Health Service Academy, École du Val-de-Grâce, Paris, France.

Introduction: The development of damage control orthopedics (DCO) procedures has led to the development of temporary unicortical external fixators (TUEFs) intended to limit deep infectious complications and facilitate early conversion to internal fixation.

Methods: A retrospective study was conducted in two French military trauma centers, including on patients being treated for tibial fractures with a TUEF (UNYCO - Orthofix) followed by an early conversion to intramedullary nailing.

Results: Eleven patients with an average age of 41 were included between September 2015 and June 2017. A total of 12 TUEFs were implanted for one closed fracture and 11 open fractures, including one type I, eight types II, and two Gustilo types IIIB. The indication of DCO was related to hemodynamic instability in three cases, to the severity of soft tissue lesions in eight cases, and to the context of treatment in one case. The conversion to IM nailing was made after an average of 7.6 days. No significant loss of reduction was observed until internal osteosynthesis, which was performed with "fixator in place" in ten cases. The coverage of Gustilo type III injuries was performed by free flap transfers at the same time as IM nailing. All the patients were reviewed with an average follow-up of 16.5 months. Bone union was achieved in all cases. Two IM nailing dynamizations were carried out, but no bone grafting was required. Two cases of pandiaphysitis were observed and treated without functional complications.

Discussion: Despite a limited number of patients, this study demonstrates the reliability of the TUEF to maintain the reduction of tibial fractures and facilitate early conversion to IM nailing. Unicortical fixation does not prevent septic complications related to the severity of soft tissue injuries.
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http://dx.doi.org/10.1051/sicotj/2018035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128168PMC
September 2018

Preparedness Evaluation of French Military Orthopedic Surgeons Before Deployment.

Mil Med 2019 01;184(1-2):e206-e212

Department of Orthopaedic, Traumatology and Reconstructive surgery, Percy Military Teaching Hospital, Clamart, France.

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http://dx.doi.org/10.1093/milmed/usy134DOI Listing
January 2019

Digital replantation in forward surgical units: a cases study.

SICOT J 2018 16;4. Epub 2018 Mar 16.

Department of orthopedic traumatology reconstructive surgery, Percy Military Hospital, Clamart, France - Department of surgery, French Military Medical Academy, Ecole du Val-de-Grâce, Paris, France.

Introduction: Noncombat-related hand injuries are common in current theatres of operations. Crushing is one of the most frequent mechanisms that may cause traumatic amputations of digits. In the military setting, management of these digital amputations is challenging regarding limitation in microsurgical means in medical treatment facilities and aeromedical evacuation delays out of the combat zone.

Methods: Two cases of digital replantation performed in French forward surgical units are described. The first case was a complete distal amputation of the medius which was successfully replanted in the operating theatre of an aircraft carrier. No complication was observed after evacuation. Functional and aesthetic results were excellent. The second case was a ring finger avulsion revascularized in a role 2 facility in Central African Republic. Unfortunately, revascularization failed due to arterial thrombosis during evacuation.

Results: Digital, hand or more proximal upper extremity replantation may be considered for isolated amputations due to work-related accidents within the combat zone. For a surgeon trained to microsurgery, a microsurgical set and magnification loupes enable to attempt such procedures in austere conditions.

Discussion: The authors propose an algorithm of management in the field according to the type and level of amputation.
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http://dx.doi.org/10.1051/sicotj/2018004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855496PMC
March 2018

Threats to large brown algal forests in temperate seas: the overlooked role of native herbivorous fish.

Sci Rep 2017 07 20;7(1):6012. Epub 2017 Jul 20.

Université Côte d'Azur, CNRS, ECOMERS, Nice, 06108, France.

Canopy-forming algae are declining globally due to multiple disturbances. This decline has recently been on the increase due to the spread of some tropical herbivorous fishes. This new phenomenon has drawn attention to the effects of fish herbivory in temperate areas, which have been assumed to be negligible compared to that of invertebrates, such as sea urchins. In this study, the impact of a Mediterranean native herbivorous fish (Sarpa salpa, salema) was assessed on the canopy-forming seaweed Cystoseira amentacea var. stricta. Cystoseira amentacea forms belts in the infralittoral fringe of wave-exposed shores, which has so far been considered a refuge from fish herbivory. To test the effects of salema feeding on natural C. amentacea belts, an innovative herbivore deterrent device was conceived. Salema had a significant effect on C. amentacea by decreasing algal size, biomass and fertility, by up to 97%. The results suggest that the contribution of salema feeding to the loss of Cystoseira forests in the Mediterranean may have been overlooked. In addition, the analysis of temporal and spatial patterns of salema landings in the Mediterranean Sea suggests that salema abundance may have increased recently. Thus, along with invertebrate herbivory and anthropogenic stressors, fish herbivory may also represent a potential threat to algal forests in temperate areas.
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http://dx.doi.org/10.1038/s41598-017-06394-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5519706PMC
July 2017

[Role of the nurse in the case of complex hand wounds].

Soins 2017 Jun;62(816):13-16

Service médical d'urgence, Brigade de sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France. Electronic address:

The initial assessment and care determine the quality of the secondary surgical treatment of complex hand wounds. The caregiver providing this initial care plays a critical role. The analysis of the management of these traumas in exceptional situations enables the key stages of the initial treatment to be identified: bleeding control, infection prevention and an accurate assessment of the injury. These measures thereby help to optimise the patient's transfer towards a specialised unit.
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http://dx.doi.org/10.1016/j.soin.2017.04.019DOI Listing
June 2017

Initial management of complex hand injuries in military or austere environments: how to defer and prepare for definitive repair?

Int Orthop 2017 09 10;41(9):1771-1775. Epub 2017 Apr 10.

Clinic of Traumatology and Orthopedics, Percy Military Hospital, Clamart, France.

Introduction: The damage control orthopedics (DCO) concept is a sequential surgical management strategy indicated when ideal primary treatment is not possible or suitable. DCO principles are routinely applied to hand traumas in wartime practice, but could also be useful in a civilian setting when immediate specialized management cannot be carried out.

Methods: The authors report three typical observations of soldiers treated for a complex hand trauma on the field by orthopedic surgeons from the French Military Health Service (FMHS). Application of the hand DCO concept is analyzed and discussed considering the literature and the FMHS experience.

Results: With regards to treating the hand, DCO necessitates a meticulous debridement with precise wound assessment, the frequent use of a primary definitive internal fixation by K-wires, and the possibility of a temporary coverage. These simple and fast procedures help avoid infection and prepare the hand for secondary repair.

Conclusion: Hand DCO can be applied by any surgeon in various situations: in association with polytrauma, complex injuries requiring multiple reconstructions, or delayed transfer to a specialized center.
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http://dx.doi.org/10.1007/s00264-017-3439-9DOI Listing
September 2017

[Assessing a patient's pain].

Authors:
Laurent Mathieu

Soins 2016 Oct;61(809):14-17

Consultation douleur, centre hospitalier Verdun Saint-Mihiel, 2, rue d'Anthouard, 55100 Verdun, France. Electronic address:

Pain assessment has taken a predominant role in nursing practice. In day-to-day care, the way a patient in pain is approached and the assessment of their pain are sometimes subject to extensive questioning. The subjective part of pain is still often emphasised when the quantified assessment and the nurse's clinical observation are contradictory. The exhaustive gathering of information is key to an effective assessment of a patient's pain.
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http://dx.doi.org/10.1016/j.soin.2016.08.001DOI Listing
October 2016