Publications by authors named "Marc Soubeyrand"

34 Publications

The ulnar interosseous tuberosity exists: a radiological and descriptive cadaveric study.

Surg Radiol Anat 2021 Jul 6. Epub 2021 Jul 6.

Department of Orthopedics and Traumatology, Clinique Saint Jean l'Ermitage, 272 Avenue Marc Jacquet, 77000, Melun, France.

Purpose: The anatomy of the ulna seems to have already been described exhaustively, particularly at its extremities, but very little in its middle third. We report the existence of an interosseous tuberosity on the interosseous border of the ulnar shaft that we have named the "tuberositas interossea ulnarii" (TIU).

Methods: First, we analyzed all side view X-rays of the forearm in neutral rotation, as well as forearm CT scans carried out during a 1-year period in our hospital. On these radiographic examinations, we evaluated the presence or absence of the TIU, its length, the thickness of the interosseous cortex at its level, above and below compared with anterior, posterior, and lateral bone cortices. In the second part of the study, we dissected cadaveric forearms to determine which ligaments and muscles were attached to it.

Results: A total of 91 standard forearm radiographs and 13 CT scans were analyzed. In all cases, the ulnar interosseous tuberosity was present. The mean tuberosity length was 107.5 mm (± 18.2), without any significant gender influence. It corresponded to a thickening (6.9 mm then 4.6 mm above and 3.9 mm below; p < 0.0001) of the ulnar interosseous cortex. Then, ten anatomic subjects (six females, four males) were dissected. We observed that this tuberosity served as an attachment for the central band of the interosseous membrane, for the deep flexor and extensor muscles for the long fingers, and for the abductor pollicis longus muscle's inner attachment.

Conclusion: Tuberositas interossea ulnarii exists besides the tuberositas interossea radii, corresponds to thickening of the cortex and may play a role in the stability of the forearm and the function of the long fingers.
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http://dx.doi.org/10.1007/s00276-021-02792-9DOI Listing
July 2021

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

CORR Insights®: A Comprehensive Enhanced Recovery Pathway for Rotator Cuff Surgery Reduces Pain, Opioid Use, and Side Effects.

Authors:
Marc Soubeyrand

Clin Orthop Relat Res 2021 Aug;479(8):1752-1753

Clinique Saint Jean l'ermitage, Service d'orthopédie, Melun, France.

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http://dx.doi.org/10.1097/CORR.0000000000001746DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8277260PMC
August 2021

Stabilization of the radial head with the palmaris longus or the gracilis tendon: an anatomical feasibility study.

Eur J Orthop Surg Traumatol 2021 May 24;31(4):651-659. Epub 2020 Oct 24.

Department of Orthopaedic Surgery, Clinique Saint Jean L'Ermitage, 272 Av MArc Jacquet, 77000, Melun, France.

Purpose: The proximal radioulnar joint (PRUJ) and the radiocapitellar joint may be destabilized after trauma. Different techniques for stabilization of PRUJ have been proposed, but none of them can stabilize the radiocapitellar joint at the same time. We propose a ligamentoplasty to stabilize the radial head at these two joints by reconstructing the radial head annular ligament and the lateral collateral ulnar ligament (LCUL) with a single graft (palmaris longus or gracilis tendon of the knee).

Methods: Fifteen cadaveric upper limbs were used to compare the stabilization obtained by performing our ligamentoplasty with the palmaris longus or the gracilis tendon. For each technique, the stabilization obtained was evaluated by measuring the displacement of the radial head in the anterior, lateral and posterior directions when a force of 1 N was applied in maximum supination, neutral rotation and maximum pronation. We also evaluated whether this technique could damage the ulnar nerve or the posterior interosseous nerve by dissecting them and whether it could limit the range of rotation of the forearm.

Results: Our ligamentoplasty enables to restore PRUJ stability equivalent to the intact ligament condition. The palmaris longus was inconstant (13/15) and too short to allow concomitant reconstruction of the LCUL (except in one case). No nerve damage was found during the dissection, and the range of rotation of the forearm was not limited by the ligamentoplasty. We also report a clinical case with an excellent result and without complications.

Conclusion: This ligamentoplasty we have described makes it possible to stabilize the radial head with respect to the radial notch of the ulna and with respect to the capitellum of the humerus. The gracilis tendon is more suitable than the palmaris longus because of its constant presence and length. A clinical series is now necessary to better evaluate this technique.
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http://dx.doi.org/10.1007/s00590-020-02815-yDOI Listing
May 2021

The interosseous tuberosity of radius: a descriptive radiological and cadaveric anatomical study.

Surg Radiol Anat 2021 May 12;43(5):727-734. Epub 2020 Oct 12.

Department of Orthopedics and Traumatology, Clinique Saint Jean L'Ermitage, 272 avenue Marc Jacquet, 77000, Melun, France.

Purpose: The radius is described with a single tuberosity: the radial tuberosity. However, we hypothesize that there is a second tuberosity on the interosseous border of the radius: which we propose to call the interosseous tuberosity - Tuberositas interossea radii - (IT).

Methods: First, we analyzed all anteroposterior radiographs of the forearm (48 females, 54 males; 62 lefts and 40 rights) as well as CT scans (6 females, 7 males; 5 lefts and 8 rights) carried out during one year in our hospital. We evaluated the presence of IT, its length, thickness of the interosseous cortex at IT level, above and below compared with anterior, posterior and lateral bone cortices. In the second part of the study, we dissected cadaveric forearms to determine which ligaments and muscles were attaches on the IT.

Results: A total of 102 standard forearm radiographs and 13 CT-scans were analyzed. In all cases, an IT was present. The mean tuberosity length was 93.9 mm (+ / - 15.8), which corresponds to 37% (+ / - 5) of total radial length. IT corresponds to a significant thickening (7.6 mm than 4.2 mm and 4.3 mm below; p < 0.0001) of radial interosseous cortex. A total of 10 forearms were dissected. In all cases, we observed that IT served as an attachment for central band of interosseous membrane and for all extrinsic muscles of the thumb with the exception of the extensor pollicis longus.

Conclusion: Tuberositas interossea radii exists, corresponds to a cortex thickening and may play a role in the stability of the forearm and the function of the thumb.
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http://dx.doi.org/10.1007/s00276-020-02594-5DOI Listing
May 2021

The paraspinal muscle-tendon system: Its paradoxical anatomy.

PLoS One 2019 8;14(4):e0214812. Epub 2019 Apr 8.

Complexité, Innovations, Activités Motrices et Sportives, CIAMS (EA4532), Paris-Sud University, Paris-Saclay University, Orsay, France.

Anatomy of the muscle-tendon system is an important component to musculoskeletal models. In particular, the cross-sectional area of belly (mCSA) and tendon (tCSA) provides information about the maximum force that a muscle may exert. The ratio of mCSA to tCSA (rCSA) demonstrates how muscle force is related to the ability to resist/transmit the force to bone. Previous anatomical studies of the lumbar paraspinal muscles (LPM) showed that their bellies have large mCSA suggesting that they are powerful muscles. Surprisingly, surgical experience shows that the tendons of the LPM are among the thinnest tendons of the body. We therefore hypothesized that traditional biomechanics of the LPM and the rCSA do not correspond for LPM. In 10 fresh-frozen old cadavers, we measured the mCSA, tCSA and rCSA of the LPM (multifidus and the erector spinae, i.e. the longissimus and the iliocostalis); then, we compared these data with those of one of the weakest muscles in the body, i.e. the extensor digitorum communis (EDC) chosen because it shares some common anatomical features with the LPM, in particular with the erector spinae. For instance, the EDC has a polyarticular course and presents long and thin effector tendons. Among the LPM, the longissimus has the greatest mean ACSA with 10.42 cm2 compared with 9.16 cm2 for the iliocostalis and 0.24 cm2 for the multifidus. Mean ACSA of the EDC was almost ten times smaller than those of erector spinae. Regarding the mean tCSA, the EDC was the largest one with 11.48 mm2 compared with 2.69 mm2 and 1.43 mm2 for the longissimus, 5.74 mm2 and 2.38 mm2for the iliocostalis and 5.28 mm2 and 4.96 mm2 for the multifidus. Mean rCSAs of the erector spinae were extremely small, ranged from 1/156 for the spinal attachment of the iliocostalis to 1/739 for the rib attachment of the longissimus that suggests that tendons are an unsuitable size to transmit the force to bone. Mean rCSA of the multifidus and the EDC were in the same range with rCSA = 1/5 and rCSA = 1/9 respectively. The rCSA of the multifidus was substantial, but its ACSA (1cm2) corresponds to low-power muscles. This paradoxical anatomy compels us to consider the biomechanics of the LPM in a different way from that of the classical "chord-like model", i.e. the muscle belly creates a force that is applied to a bone piece through a tendon. The LPM have large contractile mass in a semi-rigid compartment inside which the pressure may increase. This result strengthens the hypothesis that high pressure and intrinsic stiffness of the LPM create two stiff bodies, closely attached to the spine thus ensuring its stabilization.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0214812PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6453460PMC
January 2020

Posture-related stiffness mapping of paraspinal muscles.

J Anat 2019 06 22;234(6):787-799. Epub 2019 Mar 22.

Radiology Department, Bicêtre Hospital, APHP, Kremlin-Bicêtre, France.

The paraspinal compartment acts as a bone-muscle composite beam of the spine. The elastic properties of the paraspinal muscles play a critical role in spine stabilization. These properties depend on the subjects' posture, and they may be drastically altered by low back pain. Supersonic shear wave elastography can be used to provide quantitative stiffness maps (elastograms), which characterize the elastic properties of the probed tissue. The aim of this study was to challenge shear wave elastography sensitivity to postural stiffness changes in healthy paraspinal muscles. The stiffness of the main paraspinal muscles (longissimus, iliocostalis, multifidus) was measured by shear wave elastography at the lumbosacral level (L3 and S1) for six static postures performed by volunteers. Passive postures (rest, passive flexion, passive extension) were performed in a first shear wave elastography session, and active postures (upright, bending forward, bending backward) with rest posture for reference were performed in a second session. Measurements were repeated three times for each posture. Sixteen healthy young adults were enrolled in the study. Non-parametric paired tests, multiple analyses of covariance, and intra-class correlations were implemented for analysis. Shear wave elastography showed good to excellent reliability, except in the multifidus at S1, during bending forward, and in the multifidus at L3, during bending backward. Yet, during bending forward, only poor quality was recorded for nine volunteers in the longissimus. Significant intra- and inter-muscular changes were observed with posture. Stiffness significantly increased for the upright position and bending forward with respect to the reference values recorded in passive postures. In conclusion, shear wave elastography allows reliable assessment of the stiffness of the paraspinal muscles except in the multifidus at S1 and longissimus, during bending forward, and in the multifidus at L3, during bending backward. It reveals a different biomechanical behaviour for the multifidus, the longissimus, and the iliocostalis.
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http://dx.doi.org/10.1111/joa.12978DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6539704PMC
June 2019

Organization of the fascia and aponeurosis in the lumbar paraspinal compartment.

Surg Radiol Anat 2018 Nov 31;40(11):1231-1242. Epub 2018 Aug 31.

Laboratory "Complexité, Innovations, Activités Motrices et Sportives", CIAMS (EA4532), University Paris-Sud, University Paris-Saclay, Orsay, France.

Purpose: The thoracolumbar fascia (TLF) and the erector spinae aponeurosis (ESA) play significant roles in the biomechanics of the spine and could be a source of low back pain. Attachment, collagen fiber direction, size and biomechanical properties of the TLF have been well documented. However, questions remain about the attachment of the TLF and ESA in relation to adjoining tissues in the lumbosacral region. Moreover, quantitative data in relation to the ESA have rarely been examined. The aim of this study was to further investigate the anatomical features of the TLF and ESA and to determine the attachments and sliding areas of the paraspinal compartment through dissection.

Materials And Methods: In 10 fresh cadavers (6 females, 4 males, mean age: 77 ± 10 years), we determined (1) the gross anatomy of the ESA and the TLF (attachments and sliding areas) and (2) the structure of the ESA and the TLF (thickness, width, orientation of collagen fibers). The pennation angle between the axis of the ES muscle fibers and the axis of the collagen fibers of the ESA were also measured.

Results: The TLF is an irregular dense connective tissue with a mean thickness of 0.95 mm. The distance between the spinous processes line and the site where the neurovascular bundles pierced the TLF, depending on the vertebral level, ranged from 29 mm at L1 to 75 mm at L3. The ESA constituted a band of regular longitudinally oriented connective fibers (mean thickness: 1.85 mm). Muscles fibers of the ES were strongly diagonally attached to the ESA (mean pennation angle 8° for the iliocostalis and 14° for the longissimus). To a lesser extent, the superficial multifidi were attached to the ESA at the lumbar level close to the midline and at the sacral level.

Conclusion: The ESA, at twice the thickness of the pTLF, was the thickest dense connective tissue of the paraspinal compartment. The ESA and the TLF circumscribed subcompartments and sliding areas between the TFL and the lumbar paraspinal muscles, between the ES and the multifidus, and between the longissimus and the iliocostalis.
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http://dx.doi.org/10.1007/s00276-018-2087-0DOI Listing
November 2018

Influence of thoracolumbar fascia stretching on lumbar back muscle stiffness: A supersonic shear wave elastography approach.

Clin Anat 2019 Jan;32(1):73-80

Radiology Department, Bicêtre Hospital, APHP, France.

The lumbar paraspinal muscle compartment (PMC) is a stabilizing system of the spine whose efficiency depends on its elastic properties, which may be quantifiable by supersonic shear wave elastography (SWE). The thoracolumbar fascia (TLF) encapsulates the lumbar paraspinal muscles (LPM) and creates a PMC. Tensioning of the TLF via the stretching of the latissimus dorsi is supposed to increase stiffness within the PMC. The aims of this study were (1) to test the reliability of SWE in the multifidus and the erector spinae (ES) in prone and sited position; (2) to investigate the role of the tensioning of the pTLF, via stretching of the latissimus dorsi (LD), on LPM stiffness. Stiffness of ES and multifidus was measured using SWE at L3-L4 in procubitus and seated position in 15 participants. Stretching of LD was performed with arm elevation. Parametric paired tests, multiple analyses of variance, and intraclass correlation were used for statistical analysis. Reliability estimates were fair to excellent. Reliability was greater in ES than the multifidus, greater in seated position than during rest. Stiffness was greater in the ES than in multifidus, and in seated position than at rest. Tensioning of the TLF via LD stretching did not generate significant LPM stiffness changes. SWE is a reliable tool for assessing stiffness in the LPM. Reliability of SWE protocols is improved during seated position. Tensioning of the TLF via LD stretching did not influence LPM stiffness. Clin. Anat. 32:73-80, 2019. © 2018 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.23266DOI Listing
January 2019

Editorial: Hand surgery and anatomy.

Surg Radiol Anat 2018 09;40(9):977

Laboratory of Anatomy, Faculty of Medicine-Pharmacy, Rouen University, 22 Boulevard Gambetta, 76183, Rouen, France.

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http://dx.doi.org/10.1007/s00276-018-2067-4DOI Listing
September 2018

Magnetic resonance elastography of the lumbar back muscles: A preliminary study.

Clin Anat 2018 May;31(4):514-520

Radiology Department, Bicêtre Hospital, APHP, France.

Back pain is associated with increased lumbar paraspinal muscle (LPM) stiffness identified by manual palpation and strain elastography. Recently, magnetic resonance elastography (MRE) has allowed the stiffness of muscle to be characterized noninvasively in vivo, providing quantitative 3D stiffness maps (elastograms). The aim of this study was to characterize the stiffness (shear modulus, SM) of the LPM (multifidus and erector spinae) using MRE. MRE of the lumbar region was performed on seven adults in supine position. MRE was acquired in three muscular states: relaxed with outstretched legs, stretched with passive pelvis flexion, and contracted with outstretched legs and tightened trunk muscles. The mean SM was measured within a region of interest manually defined in the multifidus, erector spinae, and the entire paraspinal compartment. The intermuscular difference and the effects of stretching and contraction were assessed by ANOVA and t-tests. At rest, the mean SM of the paraspinal compartment was 1.6 ± 0.2 kPa. It increased significantly with stretching to 1.65 ± 0.3 kPa, and with contraction to 2.0 ± 0.7 kPa. Irrespective of muscular state, the erector spinae was significantly stiffer than the multifidus. The multifidus underwent proportionally higher stiffness changes from rest to contraction and stretching. MRE can be used to measure the stiffness of the LPM in different muscular states. We hypothesize that, irrespective of posture, the erector spinae behaves as semi-rigid beam, and ensures permanent stiffness of the spine. The multifidus behaves as an adaptable muscle that provides segmental flexibility to the spine and tunes the spine stiffness. Clin. Anat. 31:514-520, 2018. © 2018 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.23065DOI Listing
May 2018

De novo generation in an in vivo rat model and biomechanical characterization of autologous transplants for ligament and tendon reconstruction.

Clin Biomech (Bristol, Avon) 2018 02 14;52:33-40. Epub 2017 Dec 14.

Laboratoire d'Etude de la Microcirculation, Faculté de Médecine Diderot Paris VII, U942, Paris, France.

Background: Surgical reconstruction of ligaments and tendons is frequently required in clinical practice. The commonly used autografts, allografts, or synthetic transplants present limitations in terms of availability, biocompatibility, cost, and mechanical properties that tissue bioengineering aims to overcome. It classically combines an exogenous extracellular matrix with cells, but this approach remains complex and expensive. Using a rat model, we tested a new bioengineering strategy for the in vivo and de novo generation of autologous grafts without the addition of extracellular matrix or cells, and analyzed their biomechanical and structural properties.

Methods: A silicone perforated tubular implant (PTI) was designed and implanted in the spine of male Wistar rats to generate neo-transplants. The tensile load to failure, stiffness, Young modulus, and ultrastructure of the generated tissue were determined at 6 and 12weeks after surgery. The feasibility of using the transplant that was generated in the spine as an autograft for reconstruction of medial collateral ligaments (MCL) and Achilles tendons was also tested.

Findings: Use of the PTI resulted in de novo transplant generation. Their median load to failure and Young modulus increased between 6 and 12weeks (respectively 12N vs 34N and 48MPa vs 178MPa). At 12weeks, the neo-transplants exhibited collagen bundles (mainly type III) parallel to their longitudinal axis and elongated fibroblasts. Six weeks after their transfer to replace the MCL or the Achilles tendon, the transplants were still present, with their ends healed at their insertion point.

Interpretation: This animal study is a first step in the design and validation of a new bioengineering strategy to develop autologous transplants for ligament and tendon reconstructions.
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http://dx.doi.org/10.1016/j.clinbiomech.2017.12.006DOI Listing
February 2018

Combinatorial therapy with two pro-coagulants and one osmotic agent reduces the extent of the lesion in the acute phase of spinal cord injury in the rat.

Intensive Care Med Exp 2017 Dec 11;5(1):51. Epub 2017 Dec 11.

INSERM U942, Equipe universitaire 3509 Paris VII-Paris XI-Paris XIII, Microcirculation, Bioénergétique, Inflammation et Insuffisance circulatoire aiguë, Paris Diderot-Paris VII, Paris, France.

Background: Spinal cord injury (SCI) is a complex disease that leads to a motor, sensitive, and vegetative impairment. So far, single therapies are ineffective for treating SCI in humans and a multifactorial therapeutic approach may be required. The aim of this work was to assess the effect of a triple therapy (TT) associating two pro-coagulant therapies (tranexamic acid and fibrinogen) with an anti-edema therapy (hypertonic saline solution), on the extent of the lesion 24 h post-injury.

Methods: The design of this study is a randomized controlled study. The setting of this study is an experimental study. Male Wistar rats were assigned to receive saline solution for the control group or one of the treatment, or a combination of two treatments or the three treatments (triple therapy group (TT)). Animals were anesthetized and received a weight-drop SCI induced at the level of the 12th thoracic vertebra (Th12). They were treated by single therapies, double therapies, or TT started 5 min after the SCI.

Results: The extent of the lesion was assessed 24 h after injury by spectrophotometry (quantification of parenchymal hemorrhage and blood-spinal cord barrier disruption) and by histology (quantification of spared neuronal tissue). As compared with the control group, the TT significantly reduced parenchymal hemorrhage (p < 0.05) and improved the total amount of intact neural tissue, measured 24 h later (p = 0.003).

Conclusions: Combinatorial therapy associating two pro-coagulants (tranexamic acid and fibrinogen) with an anti-edema therapy (hypertonic saline solution) reduces the extent of the lesion in the acute phase of spinal cord injury in the rat.
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http://dx.doi.org/10.1186/s40635-017-0164-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725399PMC
December 2017

Shear wave sonoelastography of skeletal muscle: basic principles, biomechanical concepts, clinical applications, and future perspectives.

Skeletal Radiol 2018 Apr 9;47(4):457-471. Epub 2017 Dec 9.

Radiology Department, Bicêtre Hospital, APHP, Le Kremlin-Bicetre, France.

Imaging plays an important role in the diagnosis and therapeutic response evaluation of muscular diseases. However, one important limitation is its incapacity to assess the in vivo biomechanical properties of the muscles. The emerging shear wave sonoelastography technique offers a quantifiable spatial representation of the viscoelastic characteristics of skeletal muscle. Elastography is a non-invasive tool used to analyze the physiologic and biomechanical properties of muscles in healthy and pathologic conditions. However, radiologists need to familiarize themselves with the muscular biomechanical concepts and technical challenges of shear wave elastography. This review introduces the basic principles of muscle shear wave elastography, analyzes the factors that can influence measurements and provides an overview of its potential clinical applications in the field of muscular diseases.
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http://dx.doi.org/10.1007/s00256-017-2843-yDOI Listing
April 2018

Feasibility assessment of shear wave elastography to lumbar back muscles: A Radioanatomic Study.

Clin Anat 2017 Sep 12;30(6):774-780. Epub 2017 Jun 12.

Orthopedic Department, Bicêtre Hospital, APHP, Le Kremlin-Bicêtre, France.

Low back pain is often associated with tensional changes in the paraspinal muscles detected by palpatory procedures. Shear wave elastography (SWE), recently introduced, allows the stiffness of muscles to be assessed noninvasively. The aim of this work was to study the feasibility of using SWE on the three main lumbar back muscles (multifidus, longissimus, and iliocostalis) in vivo after analyzing their muscular architecture ex vivo. We determined the orientation of fibers in the multifidus, longissimus, and iliocotalis muscles in seven fresh cadavers using gross anatomy and B-Mode ultrasound imaging. We then quantified the stiffness of these three muscles at the L3 level ex vivo and in 16 healthy young adults. Little pennation was observed in the longissimus and iliocostalis, in which the direction of fibers was almost parallel to the line of spinous processes. The multifidus appeared as a multiceps and multipennate muscle. Given the random layering of millimetric fascicles, tendons, and fatty spaces, the multifidus had multiple fiber orientations. Muscular fascicles and fibers were oriented from 9° to 22° to the line of spinous processes. The shear moduli related to stiffness were 6.9 ± 2.7 kPa for the longissimus, 4.9 ± 1.4 kPa for the iliocostalis, and 5.4 ± 1.6 kPa for the multifidus. SWE is a feasible method for quantifying the stiffness of the lumbar back muscles. Clin. Anat. 30:774-780, 2017. © 2017Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ca.22903DOI Listing
September 2017

Hamate and pisiform coalition: a case report and introduction to the carpal C-sign on lateral radiograph.

Skeletal Radiol 2017 May 22;46(5):693-699. Epub 2017 Feb 22.

Radiology Department, Hôpital Bicêtre, 78 rue du Général Leclerc, 94266, Le Kremlin-Bicetre, France.

Hamate-pisiform coalition is an exceptional form of carpal coalition. Case reports are essential to gain a better understanding of this variant. We report a case of congenital bilateral hamate-pisiform coalition in a 20-year-old male discovered in the context of a right wrist trauma. Radiographs also revealed a bilateral scapholunate diastasis. Clinical examination and radiological findings suggested that the right wrist scapholunate diastasis was related to scapholunate instability. Left wrist scapholunate diastasis could be related to (1) a pathological feature or (2) a normal variant associated with hamate-pisiform coalition. Lateral radiographs showed a volar C-shaped osseous bridge corresponding to the coalition. We associated it with a new sign: the "carpal C-sign". Computed tomography with three-dimensional reconstruction provides helpful information about the type of coalition (osseous versus non-osseous) and excludes potential fracture. We discuss the specific embryologic features of the hamate-pisiform coalition, as well as its prevalence, radiographic classification, clinical significance, and treatment.
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http://dx.doi.org/10.1007/s00256-017-2593-xDOI Listing
May 2017

Cadaveric assessment of a 3D-printed aiming device for implantation of a hinged elbow external fixator.

Eur J Orthop Surg Traumatol 2017 Apr 10;27(3):405-414. Epub 2016 Dec 10.

Department of Orthopaedic Surgery, Universitary Hospital of Bicêtre, Public Assistance Hospital of Paris, 78 Rue General Leclerc, 94270, Le Kremlin-Bicêtre, France.

Introduction: Proper implantation of a hinged external elbow fixator (HEEF) is demanding since it requires precise alignment between the flexion-extension's and HEEF's axis. In order to optimize this alignment, we have developed a 3D-printed aiming device. The primary goal of the study was to compare the aiming device-based technique with the conventional pin technique. The secondary goal was to determine whether it is possible to share the aiming device with the surgical community.

Materials And Methods: A HEEF was implanted in cadavers with either the aiming device (n = 6) or the conventional pin technique (n = 6). For both techniques the duration of the procedure, the radiation exposure as well as the offset and angular divergence between the HEEF's and flexion-extension's axis were compared. To achieve the secondary goal, two surgeons used aiming devices 3D-printed from files sent by email in order to implant HEEF on cadaveric specimens (n = 6).

Results: Duration of the procedure was not significantly different between both techniques. However, the aiming device allowed for reduction of the number of image intensifier shots (p = 0.005), angular divergence (p = 0.02) and offset between both axes (p = 0.05). The aiming devices have been delivered less than 15 days after ordering, and they have allowed proper implantation of six HEEF.

Conclusion: The 3D-printed aiming device allowed less irradiant and more accurate implantation of HEEF. It is possible to share it with other surgeons.
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http://dx.doi.org/10.1007/s00590-016-1889-1DOI Listing
April 2017

Squared ligament of the elbow: anatomy and contribution to forearm stability.

Surg Radiol Anat 2016 Mar 18;38(2):237-44. Epub 2015 Aug 18.

Department of Orthopaedic Surgery, Universitary Hospital of Bicetre (Public Assistance Hospital of Paris), Le Kremlin-Bicêtre, France.

Objective: The present study describes the macroscopic and microscopic features of the squared ligament of the elbow (SLE). In addition, the SLE biomechanical behavior and contribution to the forearm stability were also examined.

Materials And Methods: Ten forearms from freshly frozen cadavers were used for this work. Each forearm was mounted in an experimental frame for quantification of longitudinal and transverse stability. Macroscopic features and biomechanical behavior were analyzed on dynamic videos obtained during forearm rotation. Then, the SLE was harvested from the 10 forearms for microscopic analysis on histological slices stained with hematoxylin-eosin-saffron.

Results: Two main SLE configurations were identified. One in which the SLE had three distinct bundles (anterior, middle, posterior) and another in which it was homogeneous. The anterior part of the SLE had a mean length of 11.2 mm (±2.4 mm) and a mean width of 1.2 mm (±0.2 mm) while the posterior part had a mean length of 9.9 mm (±2.2 mm) and a mean width of 1 mm (±0.2 mm). Microscopic examination showed that the SLE is composed of a thin layer of arranged collagen fibers. During forearm rotation, the SLE progressively tightens upon pronation and supination by wrapping around the radial neck. Tightening of the SLE during forearm rotation provides transverse and longitudinal stability to the forearm, mainly in maximal pronation and supination.

Conclusion: The SLE is a true ligament and provides forearm stability when it is stretched in pronation and supination.
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http://dx.doi.org/10.1007/s00276-015-1539-zDOI Listing
March 2016

Contrast enhanced ultrasound imaging for assessment of spinal cord blood flow in experimental spinal cord injury.

J Vis Exp 2015 May 7(99):e52536. Epub 2015 May 7.

Laboratoire d'étude de la microcirculation, Faculté de Médecine Paris Diderot Paris VII, U942; Department of orthopaedic surgery, Bicetre Universitary Hospital, Public Assistance of Paris Hospital;

Reduced spinal cord blood flow (SCBF) (i.e., ischemia) plays a key role in traumatic spinal cord injury (SCI) pathophysiology and is accordingly an important target for neuroprotective therapies. Although several techniques have been described to assess SCBF, they all have significant limitations. To overcome the latter, we propose the use of real-time contrast enhanced ultrasound imaging (CEU). Here we describe the application of this technique in a rat contusion model of SCI. A jugular catheter is first implanted for the repeated injection of contrast agent, a sodium chloride solution of sulphur hexafluoride encapsulated microbubbles. The spine is then stabilized with a custom-made 3D-frame and the spinal cord dura mater is exposed by a laminectomy at ThIX-ThXII. The ultrasound probe is then positioned at the posterior aspect of the dura mater (coated with ultrasound gel). To assess baseline SCBF, a single intravenous injection (400 µl) of contrast agent is applied to record its passage through the intact spinal cord microvasculature. A weight-drop device is subsequently used to generate a reproducible experimental contusion model of SCI. Contrast agent is re-injected 15 min following the injury to assess post-SCI SCBF changes. CEU allows for real time and in-vivo assessment of SCBF changes following SCI. In the uninjured animal, ultrasound imaging showed uneven blood flow along the intact spinal cord. Furthermore, 15 min post-SCI, there was critical ischemia at the level of the epicenter while SCBF remained preserved in the more remote intact areas. In the regions adjacent to the epicenter (both rostral and caudal), SCBF was significantly reduced. This corresponds to the previously described "ischemic penumbra zone". This tool is of major interest for assessing the effects of therapies aimed at limiting ischemia and the resulting tissue necrosis subsequent to SCI.
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http://dx.doi.org/10.3791/52536DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542508PMC
May 2015

Very high resolution ultrasound imaging for real-time quantitative visualization of vascular disruption after spinal cord injury.

J Neurotrauma 2014 Nov 4;31(21):1767-75. Epub 2014 Sep 4.

1 Division of Genetics and Development, Toronto Western Research Institute, Krembil Neuroscience Program, University Health Network , Toronto, Ontario, Canada .

Spinal cord injury (SCI) is characterized by vascular disruption with intramedullary hemorrhage, alterations in blood-spinal cord barrier integrity, and perilesional ischemia. A safe and easily applied imaging technique to quantify evolving intraspinal vascular changes after SCI is lacking. We evaluated the utility of very high resolution ultrasound (VHRUS) imaging to assess SCI-induced vascular disruption in a clinically relevant rodent model. The spinal cords of Wistar rats were lesioned at the 11th thoracic vertebra (Th11) by a 35 g 1-minute clip compression. Three-dimensional quantification of intraspinal hemorrhage using VHRUS (at an acute 90-min and subacute 24-h time point post-SCI) was compared with lesional hemoglobin and extravasated Evans blue dye measured spectrophotometrically. The anatomy of hemorrhage was comparatively assessed using VHRUS and histology. Time-lapse videos demonstrated the evolution of parenchymal hemorrhage. VHRUS accurately depicted the structural (gray and white matter) and vascular anatomy of the spinal cord (after laminectomy) and was safely repeated in the same animal. After SCI, a hyperechoic signal extended from the lesion epicenter. Significant correlations were found between VHRUS signal and hemorrhage in the acute (r=0.88, p<0.0001) and subacute (r=0.85, p<0.0001) phases and extravasated Evans blue (a measure of vascular disruption) in the subacute phase (r=0.94, p<0.0001). Time-lapse videos demonstrated that the expanding parenchymal hemorrhage is preceded by new perilesional hemorrhagic foci. VHRUS enables real-time quantitative live anatomical imaging of acute and subacute vascular disruption after SCI in rats. This technique has important scientific and clinical translational applications.
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http://dx.doi.org/10.1089/neu.2013.3319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4186763PMC
November 2014

Effect of norepinephrine on spinal cord blood flow and parenchymal hemorrhage size in acute-phase experimental spinal cord injury.

Eur Spine J 2014 Mar 14;23(3):658-65. Epub 2013 Nov 14.

"Microcirculation, Bioénergétique, Inflammation et Insuffisance Circulatoire Aiguë", Equipe Universitaire 3509 Paris VII-Paris XI-Paris XIII, Paris, France,

Purpose: In the acute phase of spinal cord injury (SCI), ischemia and parenchymal hemorrhage are believed to worsen the primary lesions induced by mechanical trauma. To minimize ischemia, keeping the mean arterial blood pressure above 85 mmHg for at least 1 week is recommended, and norepinephrine is frequently administered to achieve this goal. However, no experimental study has assessed the effect of norepinephrine on spinal cord blood flow (SCBF) and parenchymal hemorrhage size. We have assessed the effect of norepinephrine on SCBF and parenchymal hemorrhage size within the first hour after experimental SCI.

Methods: A total of 38 animals were included in four groups according to whether SCI was induced and norepinephrine injected. SCI was induced at level Th10 by dropping a 10-g weight from a height of 10 cm. Each experiment lasted 60 min. Norepinephrine was started 15 min after the trauma. SCBF was measured in the ischemic penumbra zone surrounding the trauma epicenter using contrast-enhanced ultrasonography. Hemorrhage size was measured repeatedly on parasagittal B-mode ultrasonography slices.

Results: SCI was associated with significant decreases in SCBF (P = 0.0002). Norepinephrine infusion did not significantly modify SCBF. Parenchymal hemorrhage size was significantly greater in the animals given norepinephrine (P = 0.0002).

Conclusion: In the rat, after a severe SCI at the Th10 level, injection of norepinephrine 15 min after SCI does not modify SCBF and increases the size of the parenchymal hemorrhage.
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http://dx.doi.org/10.1007/s00586-013-3086-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3940804PMC
March 2014

Diaphragmatic function is preserved during severe hemorrhagic shock in the rat.

Anesthesiology 2014 Feb;120(2):425-35

From the Department of Pneumology and Medical Intensive Care and ER10, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Université Pierre et Marie Curie-Paris 6, Paris, France (S.C.); ER10 and UMR INSERM, Université Pierre et Marie Curie, Paris, France (M.L.D.); Department of Orthopedic Surgery, Hôpital de Bicêtre, APHP, and ER 3509, Université Paris Sud, Le Kremlin-Bicêtre, Paris, France (M.S.); Department of Emergency Medicine and Surgery, Hôpital Pitié-Salpêtrière, APHP, UMR INSERM 956 and Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie-Paris 6 (M.-P.P.); Department of Emergency Medicine and Surgery, Hôpital Pitié-Salpêtrière, UMR INSERM 956 and Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie-Paris 6 (B.R.); Department of Pneumology and Medical Intensive Care, Hôpital Pitié-Salpêtrière, and ER10, Université Pierre et Marie Curie (T.S.); UMRS INSERM 974-CNRS 7215, Institut de Myologie, Université Pierre et Marie Curie-Paris 6 UM76, Paris, France (C.C.); and Department of Pneumology and Medical Intensive Care, Hôpital Pitié-Salpêtrière, and UMR INSERM 974-CNRS 7215, Université Pierre et Marie Curie-Paris 6 (A.D.).

Background: Acute diaphragmatic dysfunction has been reported in septic and cardiogenic shock, but few data are available concerning the effect of hemorrhagic shock on diaphragmatic function. The authors examined the impact of a hemorrhagic shock on the diaphragm.

Methods: Four parallel groups of adult rats were submitted to hemorrhagic shock induced by controlled exsanguination targeting a mean arterial blood pressure of 30 mmHg for 1 h, followed by a 1-h fluid resuscitation with either saline or shed blood targeting a mean arterial blood pressure of 80 mmHg. Diaphragm and soleus strip contractility was measured in vitro. Blood flow in the muscle microcirculation was measured in vivo using a Laser Doppler technique. Muscle proinflammatory cytokine concentrations were also measured.

Results: Hemorrhagic shock was characterized by a decrease in mean arterial blood pressure to 34 ± 5 mmHg (-77 ± 4%; P< 0.05) and high plasma lactate levels (7.6 ± 0.9 mM; P < 0.05). Although tetanic tension of the diaphragm was not altered, hemorrhagic shock induced dramatic impairment of tetanic tension of the soleus (-40 ± 19%; P < 0.01), whereas proinflammatory cytokine levels were low and not different between the two muscles. Resuscitation with either blood or saline did not further modify either diaphragm or soleus performance and proinflammatory cytokine levels. The shock-induced decrease in blood flow was much more pronounced in the soleus than in the diaphragm (-75 ± 13% vs. -17 ± 10%; P = 0.02), and a significant interaction was observed between shock and muscle (P < 0.001).

Conclusion: Diaphragm performance is preserved during hemorrhagic shock, whereas soleus performance is impaired, with no further impact of either blood or saline fluid resuscitation.
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http://dx.doi.org/10.1097/ALN.0000000000000011DOI Listing
February 2014

Rat model of spinal cord injury preserving dura mater integrity and allowing measurements of cerebrospinal fluid pressure and spinal cord blood flow.

Eur Spine J 2013 Aug 19;22(8):1810-9. Epub 2013 Mar 19.

Equipe universitaire 3509 Paris VII-Paris XI-Paris XIII, Microcirculation, Bioénergétique, Inflammation et Insuffisance circulatoire aiguë, Paris Diderot-Paris VII University, Paris, France.

Purposes: Cerebrospinal fluid (CSF) pressure elevation may worsen spinal cord ischaemia after spinal cord injury (SCI). We developed a rat model to investigate relationships between CSF pressure and spinal cord blood flow (SCBF).

Methods: Male Wistar rats had SCI induced at Th10 (n = 7) or a sham operation (n = 10). SCBF was measured using laser-Doppler and CSF pressure via a sacral catheter. Dural integrity was assessed using subdural methylene-blue injection (n = 5) and myelography (n = 5).

Results: The SCI group had significantly lower SCBF (p < 0.0001) and higher CSF pressure (p < 0.0001) values compared to the sham-operated group. Sixty minutes after SCI or sham operation, CSF pressure was 8.6 ± 0.4 mmHg in the SCI group versus 5.5 ± 0.5 mmHg in the sham-operated group. No dural tears were found after SCI.

Conclusion: Our rat model allows SCBF and CSF pressure measurements after induced SCI. After SCI, CSF pressure significantly increases.
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http://dx.doi.org/10.1007/s00586-013-2744-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3731496PMC
August 2013

Real-time and spatial quantification using contrast-enhanced ultrasonography of spinal cord perfusion during experimental spinal cord injury.

Spine (Phila Pa 1976) 2012 Oct;37(22):E1376-82

Equipe Universitaire 3509, Paris VII-Paris XI-Paris XIII, Paris, France.

Study Design: Experimental study in male Wistar rats.

Objective: To quantify temporal and spatial changes simultaneously in spinal cord blood flow and hemorrhage during the first hour after spinal cord injury (SCI), using contrast-enhanced ultrasonography (CEU).

Summary Of Background Data: Post-traumatic ischemia and hemorrhage worsen the primary lesions induced by SCI. Previous studies did not simultaneously assess temporal and spatial changes in spinal cord blood flow.

Methods: SCI was induced at Th10 in 12 animals, which were compared with 11 sham-operated controls. Spinal cord blood flow was measured in 7 adjacent regions of interest and in the sum of these 7 regions. Blood flow was quantified using CEU with intravenous microbubble injection. Spinal cord hemorrhage was measured on conventional B-mode sonogram slices.

Results: CEU allowed us to measure the temporal and spatial changes in spinal cord blood flow in both groups. In the SCI group, spinal cord blood flow was significantly decreased in the global region of interest (P = 0.0016), at the impact site (epicenter), and in the 4 regions surrounding the epicenter, compared with the sham group. The blood flow decrease was maximum at the epicenter. No statistically significant differences between the sham groups were found for the most rostral and caudal regions of interest. Hemorrhage size increased significantly with time (P < 0.0001), from 30.3 mm(2) (±2) after 5 minutes to 39.6 mm(2) (±2.3) after 60 minutes.

Conclusion: CEU seems reliable for quantifying temporal and spatial changes in spinal cord blood flow. After SCI, bleeding occurs in the spinal cord parenchyma and increases significantly throughout the first hour.
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http://dx.doi.org/10.1097/BRS.0b013e318269790fDOI Listing
October 2012

Intraoperative ultrasonography during percutaneous Achilles tendon repair.

Foot Ankle Int 2010 Dec;31(12):1069-74

Hopital Universitaire de Bicetre, AP-HP, Univ Paris-Sud, Department of Orthopedic Surgery, 78 rue du General Leclerc, 94270 Le Kremlin-Bicetre, France.

Background: The purpose of the study was to determine whether real-time intraoperative ultrasonography improved implant positioning and stump approximation in patients with acute Achilles tendon rupture managed percutaneously.

Materials And Methods: The needles were introduced percutaneously without ultrasonography and their position was checked relative to cutaneous landmarks and by palpation. Then, intraoperative ultrasonography was performed to assess needle position at the proximal tendon segment, tendon tear, and distal tendon segment. Incorrectly placed needles were removed and reinserted under real-time ultrasonographic guidance. Tendon apposition was checked ultrasonographically.

Results: We included 21 patients (19 males, two females) with unilateral acute Achilles tendon rupture, in whom 42 needles (one medial and one lateral) were inserted. Correct positioning was achieved without ultrasonographic guidance for 19 (45%) needles overall, 15 of 21 (71%) medial needles, and four of 21 (19%) lateral needles. The remaining 23 needles were correctly repositioned under ultrasonographic guidance. The correct positioning rates with and without ultrasonography differed significantly for all needles (p < 0.0001) and for lateral needles (p < 0.0001) but not for medial needles (p = 0.03). Intraoperative ultrasonography confirmed tendon stump approximation in all cases.

Conclusion: Without imaging, 55% of needles were correctly positioned. Intraoperative ultrasonography allowed correct positioning of all needles and provided intraoperative confirmation of stump approximation.
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http://dx.doi.org/10.3113/FAI.2010.1069DOI Listing
December 2010

Preoperative imaging study of the spinal cord vascularization: interest and limits in spine resection for primary tumors.

Eur J Radiol 2011 Jan 18;77(1):26-33. Epub 2010 Dec 18.

Hôpital Universitaire de Bicetre, AP-HP, Bicetre F-94270, Université Paris-Sud, Department of Orthopaedic Surgery, Le Kremlin-Bicetre, France.

The necessicity to localize the anterior spinal arteries before anterior approach of the spine stays controversial by orthopaedic surgeons. On the other hand the surgical treatment of thoracoabdominal aneurisms routinely sacrifices many segmental arteries pairs without spinal arteries localization. This, associated with spinal cord protection, results to few neurological complication. However, during vertebrectomies, the roots ligation completely interrupts the spinal cord blood supply at this level. In our experience the spinal arteries localization was systematically done before ninety-eight spine resections. In five cases an anterior radiculomedullary artery was ligated (four anterior radiculomedullary and one great anterior radiculomedullary arteries) without neurological complication, in two cases of extended resection (more than four levels) a neurological complication occurred. No spinal artery was identified at the resection level and the neurological complications were resolutive and did not seem related to definitive vascular problem. These accomplishments lead to discuss the importance of spinal arteries localization and preservation in this surgery. The discovery of an anterior radiculomedullary artery is not a contraindication to en-bloc vertebrectomy at this level, nevertheless in the case of great anterior radiculomedullary artery (Adamkiewicz) the surgical indication must be seriously debated. In fact, this case and those where multilevel resections (more than three levels) are indicated seem the most dangerous situations and the use of the different means of spinal cord protection could be indicated to decrease neurological risk. So before spine resection the spinal arteries localization could improve patient information and give more deciding factors for planning treatment.
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http://dx.doi.org/10.1016/j.ejrad.2010.06.054DOI Listing
January 2011

Severe open ankle sprain (SOAS): a lesion presenting as a penetrating soft tissue injury.

J Foot Ankle Surg 2010 May-Jun;49(3):253-8

Hôpital Universitaire de Bicetre, AP-HP, Univ Paris-Sud, Department of Orthopedic Surgery, 94270 Le Kremlin-Bicetre, France.

The objective of this retrospective case study was to describe the incidence and clinical features of severe open ankle sprain (SOAS), defined as a tear of the lateral or medial collateral ligaments with an associated transverse tear of the skin over the corresponding malleolus. To this end, we reviewed the medical records of patients with SOAS managed between January 2005 and January 2009, using the databases of 3 different orthopedic trauma centers. Our review revealed 9 patients with SOAS, 7 (77.77%) of which involved the lateral ligaments and 2 (22.22%) of which involved the medial ligaments. The median age was 32 (range 21 to 45) years, and the injury occurred as a result of a motor vehicle accident in 6 (66.67%) patients, and as a result of a fall from a height in 3 (33.33%) patients. Two tendons were damaged in 2 (22.22%) patients, the deep fibular nerve (deep peroneal nerve) in 2 (22.22%) patients, and the anterior tibial artery in 1 (11.11%) patient. The only abnormality on plain radiographs was pneumarthrosis, which was present in 5 (55.56%) patients. The incidence of SOAS is rare, accounting for 0.002% (9/438,000) of all trauma cases and 0.22% (9/4142) of all cases of ankle trauma. The diagnosis was confirmed by intraoperative stress-maneuvers in all 9 patients. In conclusion, SOAS should be suspected in patients who present with a traumatic skin wound over the malleolus.
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http://dx.doi.org/10.1053/j.jfas.2010.02.009DOI Listing
October 2010

Comparison of percutaneous dorsal versus volar fixation of scaphoid waist fractures using a computer model in cadavers.

J Hand Surg Am 2009 Dec;34(10):1838-44

Department of Orthopaedic Surgery, Hôpital Universitaire de Bicetre, Le Kremlin-Bicetre, France.

Purpose: Percutaneous screw fixation (PSF) is widely used to treat acute nondisplaced scaphoid waist fractures. PSF can be performed through a volar or dorsal approach. The aim of our study was to compare a dorsal versus volar surgical approach for PSF according to the sagittal orientation of the waist fracture (B1 or B2 in Herbert and Fisher's classification scheme, in which B1 and B2 designate, respectively, oblique and transverse nondisplaced scaphoid waist fractures) on computer modeling of cadaver wrists.

Methods: We used 12 upper limbs, and for each wrist we performed 3 computed tomography scans in maximal flexion, neutral position, and maximal extension. For each position, a parasagittal slice corresponding to the plane of ideal screw placement was obtained by numerical reconstruction. On each slice, we modeled B1- and B2-type fractures and the placement of the corresponding screws (S1 and S2) inserted through a volar or dorsal approach. Optimal screw orientation was perpendicular to the fracture. For each configuration, we measured the angle between the S1 screw and B1 fracture, which we designated V1 when modeling volar PSF and D1 when modeling dorsal PSF. Similarly, we measured angles V2 and D2.

Results: For B2 fractures, virtual screw placement perpendicular to the fracture was achieved equally well with the 2 approaches. For B1 fractures, the virtual screw could not be placed perpendicular to the fracture with either approach, but the dorsal approach with maximal wrist flexion allowed the best screw placement.

Conclusions: For B2 fractures, the dorsal and volar approaches allow optimal virtual screw placement, and the choice of the approach depends on the surgeon's preference. For B1 fractures, we recommend the dorsal approach.
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http://dx.doi.org/10.1016/j.jhsa.2009.07.012DOI Listing
December 2009

Cadaveric assessment of a new guidewire insertion device for volar percutaneous fixation of nondisplaced scaphoid fracture.

Injury 2009 Jun 21;40(6):645-51. Epub 2009 Apr 21.

Hopital Universitaire de Bicetre, AP-HP, Bicetre F-94270, Univ Paris-Sud, Department of Orthopaedic Surgery, 78 rue du General Leclerc, 94270 Le Kremlin-Bicetre, France.

Purpose: Volar percutaneous screw fixation (PSF) of acute nondisplaced scaphoid waist fractures allows early mobilisation of the wrist and a faster return to work than prolonged cast immobilisation. Usually, placement of the wire which guides the definitive canulated screw is performed by hand. Nevertheless, correct placement of this wire is technically difficult. We designed a guidewire insertion device (GID) to facilitate this placement.

Methods: We compared the hand held technique with the technique using the GID in a cadaveric study. The hand held technique was performed on 16 scaphoids and the GID was used in 16 other scaphoids. The four participating surgeons were divided into two groups: two experienced surgeons and two inexperienced surgeons.

Results: The GID significantly decreased procedure duration (P<0.001), number of attempts to place the wire (P<0.001), and number of image-intensifier shots (P<0.001). With both techniques, experienced surgeons were significantly faster (P=0.0083) and required significantly fewer attempts (P=0.043) than inexperienced surgeons. Using the GID, the procedure duration (P=0.0039) and the number of image-intensifier shots (P<0.001) decreased more with inexperienced surgeons than with experienced surgeons. As for the number of attempts, there was no statistical difference between the two groups (P=0.32).

Conclusions: The GID decreased the time and radiation exposure needed to achieve correct volar percutaneous wire placement in the scaphoid, compared to the conventional hand held technique. Easier wire placement may lead surgeons to use PSF instead of prolonged cast immobilisation for treating nondisplaced scaphoid fractures.
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http://dx.doi.org/10.1016/j.injury.2009.01.131DOI Listing
June 2009

Penetrating volar injuries of the hand: diagnostic accuracy of US in depicting soft-tissue lesions.

Radiology 2008 Oct;249(1):228-35

Department of Radiology, Saint Antoine Hospital, Public Assistance Hospital of Paris, Paris, France.

Purpose: To evaluate the effectiveness of ultrasonography (US) in depicting lesions of the tendons, arteries, and nerves caused by penetrating wounds of the volar aspect of the hand, with surgical exploration as the reference standard.

Materials And Methods: Consecutive patients seen at one center over a 2-month period in 2006 were prospectively included. The institutional review board approved the study, and each patient gave written informed consent. There were 30 injuries in 26 patients (19 men and seven women; median age, 34 years). US examination was performed before surgery. Surgeons were not informed of the US findings. For tendons, arteries, and nerves, the sensitivity, specificity, positive predictive value, and negative predictive value of US were computed.

Results: US depicted all tendon lesions, with no false-positive findings; two arterial lesions were missed, with no false-positive findings, and four nerve lesions were missed, with six false-positive findings. The negative predictive value was 100% (95% confidence interval: 95.5%, 100%) for tendons, 96.7% (95% confidence interval: 88.7%, 99.6%) for arteries, and 93.7% (95% confidence interval: 84.5%, 98.2%) for nerves. In three cases, US depicted foreign bodies missed at surgery.

Conclusion: US was highly effective in identifying patients with no tendon or arterial lesions. Performance was poorer for diagnosing nerve lesions. US followed by a repeat physical examination after 72 hours to look for missed nerve damage may deserve evaluation as an alternative to routine surgical exploration when US findings are normal.
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http://dx.doi.org/10.1148/radiol.2491071679DOI Listing
October 2008
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