[Profile and immune environment of upper tract urothelial carcinoma]. / Profil et environnement immunitaires des tumeurs de la voie excrétrice supérieure.

INTRODUCTION AND OBJECTIVES: Upper Tract Urothelial Carcinoma (UTUC) are tumors that share similarities with bladder tumors. Immunotherapy is already used for bladder locations and appears to have interest for UTUC. In order to rationalize the immunotherapy development pipeline it seemed necessary to describe the immune infiltrate of a cohort of UTUC treated with nephroureterectomy and to determine the expression of a panel of immune checkpoints and co-stimulatory molecules on tumor cells as well as on infiltrating and circulating lymphocytes. MATERIALS AND METHODS: This is a monocentric, prospective and exploratory work. Patients treated with total nephroureterectomy or segmental ureterectomy for presumably infiltrative (≥ T1) UTUC managed at the Saint-Louis Hospital were included from January 2019 to July 2020. A set of markers and immune checkpoints were studied by flow fluorocytometry on circulating lymphocytes (PBMCs) and tumor-infiltrating lymphocytes (TILs). Some markers were also studied by immunohistochemistry on tumor sample. RESULTS: In total, 14 patients were included and 13 patients could be analyzed. 1 patient had no residual tumor. 5 tumors out of the 12 (41.7%) showed a lymphocytic inflammatory infiltrate. PD1 was the most represented checkpoint with a median expression rate of 41.4% on CD4+ TILs and 3.89% on circulating CD4+ T cells. This rate was 62.4% and 7.45% respectively on CD8+ T cells. TIGIT was the second most represented marker with a median expression rate on tumor-infiltrating CD4+ T cells of 25% and 2.9% on circulating CD4+ T cells. The median expression level of TIGIT on tumor-infiltrating CD8+ T cells was 23.3% and 3.2% on circulating CD8+ T cells. ICOS was highly expressed on CD4+ TILS with a median of 33.9% in contrast to CD8+ TILS (median: 6.67%). Variable expression of other checkpoints (ILT2, TIM3, LAG3 and OX40) was found without clear trend. CONCLUSION: This exploratory work highlighted that PD1 was the most represented checkpoint. TIGIT was the second most represented checkpoint while ICOS, TIM3 and LAG3 were 3 other checkpoints whose expression was found to be less important. ILT2 and OX40 appeared to be weakly expressed. LEVEL OF EVIDENCE: II.

[Preoperative chemotherapy for patients with upper tract urothelial carcinoma: Impact on renal function]. / Chimiothérapie préopératoire des tumeurs des voies excrétrices supérieures : impact sur la fonction rénale.

PURPOSE: Upper tract urothelial carcinoma (UTUC) are rare tumors with a poor prognosis. The standard treatment for localized disease is based on total nephroureterectomy (NUT) followed by platinum-based adjuvant chemotherapy for eligible patients at risk of recurrence. However, many patients have renal failure after surgery preventing chemotherapy. Thus, the place of preoperative chemotherapy (POC) is questioned with little information available about renal toxicity and efficacity. METHODS: A single center retrospective study was performed on patients with UTUC who received POC. RESULTS: In all, 24 patients with localized UTUC were treated with POC between 2013 and 2022. Twenty-one (91%) had secondarily NUT. In this cohort, POC did not result in degradation of median renal function (pre-POC median GFR: 70mL/min, post-POC median GFR: 77mL/min, P=0.79), unlike NUT (post-NUT median GFR: 51.5mL/min, P<0.001). In addition, the rate of complete pathological response to pathological examination was 29%. After a median follow-up of 27.4 months, the overall survival rate was 74% and the recurrence-free survival rate was 46%. CONCLUSION: POC for UTUC shows a very reassuring renal toxicity profile and encouraging histological results. These data encourage prospective studies assessing its place for UTUC management.

Urachal carcinoma: a large retrospective multicentric study from the French Genito-Urinary Tumor Group.

Introduction: Urachal cancer (UrC) is a rare, non-urothelial malignancy. Its natural history and management are poorly understood. Although localized to the bladder dome, the most common histological subtype of UrC is adenocarcinoma. UrC develops from an embryonic remnant, and is frequently diagnosed in advanced stage with poor prognosis. The treatment is not standardized, and based only on case reports and small series. This large retrospective multicentric study was conducted by the French Genito-Urinary Tumor Group to gain a better understanding of UrC. Material and Methods: data has been collected retrospectively on 97 patients treated at 22 French Cancer Centers between 1996 and 2020. Results: The median follow-up was 59 months (range 44-96). The median age at diagnosis was 53 years (range 20-86), 45% were females and 23% had tobacco exposure. For patients with localized disease (Mayo I-II, n=46) and with lymph-node invasion (Mayo III, n=13) median progression-free-survival (mPFS) was 31 months (95% CI: 20-67) and 7 months (95% CI: 6-not reached (NR)), and median overall survival (mOS) was 73 months (95% CI: 57-NR) and 22 months (95% CI: 21-NR) respectively. For 45 patients with Mayo I-III had secondary metastatic progression, and 20 patients were metastatic at diagnosis. Metastatic localization was peritoneal for 54% of patients. Most patients with localized tumor were treated with partial cystectomy, with mPFS of 20 months (95% CI: 14-49), and only 12 patients received adjuvant therapy. Metastatic patients (Mayo IV) had a mOS of 23 months (95% CI: 19-33) and 69% received a platin-fluorouracil combination treatment. Conclusion: UrC is a rare tumor of the bladder where patients are younger with a higher number of females, and a lower tobacco exposure than in standard urothelial carcinoma. For localized tumor, partial cystectomy is recommended. The mOS and mPFS were low, notably for patients with lymph node invasion. For metastatic patients the prognosis is poor and standard therapy is not well-defined. Further clinical and biological knowledge are needed.

[Monochorionic biamniotic twin pregnancies outcomes in Reunion Island with indication of in utero transfert]. / Prise en charge des grossesses monochoriales biamniotiques réunionnaises avec indication de transfert in utero.

OBJECTIVE: Complicated monochorionic biamniotic (MCBA) twin pregnancies may require treatment with fetoscopic laser photocoagulation, in case of Twin Oligo-Polyhydramnios Sequence or need of a selective termination of pregnancy. Patients requiring these treatments would need medical transfer to Metropolitan France because these are unavailable in Réunion Island. We evaluated the outcomes of MCBA pregnancies in Reunion Island with indications for fetoscopy, with a view to discussing the interest of training doctors on the Reunion Island, to practice fetoscopy on site. MATERIALS AND METHODS: Retrospective hospital study running from 2015 to 2018. We included all MCBA pregnancies between 15 and 25 weeks of gestation, with indications for in utero transfer. Our objective was to examine whether and why they were transferred and pregnancy outcomes. RESULTS: Of the 23 patients, 17 (73.9%) benefited from sanitary transfers. The survival rate of the fetuses in 15 pregnancies with Twin Oligo-Polyhydramnios Sequence (TOPS) was 73.3% for one twin and 53.3% for both twins. For the eight cases of Selective Termination of the pregnancy (ST), the survival rate of the twin was better with a transfer (n=5/6, 83.3%) than without a transfer (n=1/2 or 50%). The rate of premature rupture of the membranes after sanitary transfer among patients with TOPS was 63.6%. CONCLUSION: The sanitary transfer allows the management in expert center of complicated MCBA twin pregnancies, but is not always feasible and is accompanied by a high rate of premature ruptures of membranes.

Salvage Percutaneous Cryoablation for Bleeding Upper Tract Urothelial Carcinoma.

PURPOSE: Endoscopic access and treatment of bleeding upper urinary tract urothelial carcinomas (UTUCS) is sometimes difficult and inefficient as resection and/or laser coagulation are often incomplete. We report two cases of successful cryoablation of bleeding UTUCs. MATERIALS AND METHODS: This study evaluated an adjunctive method in using cryoablation as a hemostatic technique. Cryoprobes were inserted inside the affected calices and a standard renal cryoablation protocol was used. Track ablation was performed during the pullback of the cryoprobes to prevent tumor seeding and bleeding. RESULTS: Cryoablation of the bleeding upper urinary tract tumors allowed to efficiently resolve macrohematuria in both patients and to provide prolonged remission in one patient. CONCLUSIONS: Taking advantage of the microcirculatory stasis and the hemostatic properties of cryoablation, we achieved palliative cessation of refractory macrohematuria while sparing nephrons, without the need for renal embolization in patients with bleeding UTUCs.

Malnutrition is highly prevalent in hospitalized cirrhotic patients and associates with a poor outcome.

Background and study aims: The role of malnutrition on the prognosis of hospitalized cirrhotic patients is incompletely studied. Our aim was to determine the prevalence of malnutrition, functional scores and their impact on prognosis of hospitalized cirrhotic patients. Patients and methods: This retrospective study included all patients with cirrhosis hospitalized in the gastroenterology unit at Saint-Luc university hospital, Brussels between April 2014 and September 2014. Nutritional status was evaluated according to minimum clinical summary diagnostic criteria. Cirrhosis-related complications or death occurrence were analysed in a one-year follow-up. Results: 95 cirrhotic patients were assessed for nutritional status and outcomes. Malnutrition affected 45.3% of patients and was more frequent with the severity of cirrhosis: 29% in Child-Pugh A, 48.8% in Child-Pugh B and 72.2% in Child-Pugh C patients. 58.9% of patients developed cirrhosis-related complications (60.7% in the malnutrition group vs. 39.3%, p<0.001, OR 5.06, IC95 1.90-14.58) and 33.7% of patients died (68.75% vs. 31.25%, p=0.002, OR 4.33, IC95 1.62-12.28). Adjusting for age, sodium, MELD, Charlson index, hepatocellular carcinoma, platelets, diabetes, prognostic nutritional index and Braden scale, malnutrition was significantly associated with higher mortality and morbidity rates with an OR of 3.56 (CI95 1.55-8.16) and 2.09 (CI95 1.16-3.77) respectively. Braden scale was significantly associated with higher mortality (p=0.027, OR 1.25, CI95 1.03-1.52) whereas prognostic nutritional index was associated with higher morbidity (p=0.001, OR 0.94, CI95 0.90-0.98). Conclusion: Malnutrition is highly prevalent in hospitalized cirrhotic patients. Malnutrition, low prognostic nutritional index and low Braden scale are associated with poor outcomes in cirrhosis.

Safety of systemic anti-cancer treatment in oncology patients with non-severe COVID-19: a cohort study.

BACKGROUND: The viral pandemic coronavirus disease 2019 (COVID-19) has disrupted cancer patient management around the world. Most reported data relate to incidence, risk factors, and outcome of severe COVID-19. The safety of systemic anti-cancer therapy in oncology patients with non-severe COVID-19 is an important matter in daily practice. METHODS: ONCOSARS-1 was a single-center, academic observational study. Adult patients with solid tumors treated in the oncology day unit with systemic anti-cancer therapy during the initial phase of the COVID-19 pandemic in Belgium were prospectively included. All patients (n = 363) underwent severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) serological testing after the first peak of the pandemic in Belgium. Additionally, 141 of these patients also had a SARS-CoV-2 RT-PCR test during the pandemic. The main objective was to retrospectively determine the safety of systemic cancer treatment, measured by the rate of adverse events according to the Common Terminology Criteria for Adverse Events, in SARS-CoV-2-positive patients compared with SARS-CoV-2-negative patients. RESULTS: Twenty-two (6%) of the 363 eligible patients were positive for SARS-CoV-2 by RT-PCR and/or serology. Of these, three required transient oxygen supplementation, but none required admission to the intensive care unit. Hematotoxicity was the only adverse event more frequently observed in SARS-CoV-2 -positive patients than in SARS-CoV-2-negative patients: 73% vs 35% (P < 0.001). This association remained significant (odds ratio (OR) 4.1, P = 0.009) even after adjusting for performance status and type of systemic treatment. Hematological adverse events led to more treatment delays for the SARS-CoV-2-positive group: 55% vs 20% (P < 0.001). Median duration of treatment interruption was similar between the two groups: 14 and 11 days, respectively. Febrile neutropenia, infections unrelated to COVID-19, and bleeding events occurred at a low rate in the SARS-CoV-2-positive patients. CONCLUSION: Systemic anti-cancer therapy appeared safe in ambulatory oncology patients treated during the COVID-19 pandemic. There were, however, more treatment delays in the SARS-CoV-2-positive population, mainly due to a higher rate of hematological adverse events.

Cytometry-based analysis of HLA-G functions according to ILT2 expression.

HLA-G was described as a molecule inhibiting NK and T cells functions through its receptor, ILT2. However, most functional studies of HLA-G were so far performed on heterogeneous immune populations and regardless of ILT2 expression. This may lead to an underestimation of the effect of HLA-G. Thus, considering the immune subpopulations sensitive to HLA-G remained an important issue in the field. Here we present a new cytometry assay to evaluate HLA-G effects on both NK and CD8+ T cell cytotoxic functions. Using flow cytometry allows for the comparison of HLA-G function on multiple subsets and multiple functions in the same time. In particular, we sharpen the analysis by specifically studying the immune subpopulations expressing HLA-G receptor ILT2. We focused our work on: IFN-gamma production and cytotoxicity (CD107a expression) by CD8+ T cells and NK cells expressing or not ILT2. We compared the expression of these markers in presence of target cells, expressing or not HLA-G1, and added a blocking antibody to reverse HLA-G inhibition. This new method allows for the discrimination of cell subsets responding and non-responding to HLA-G1 in one tube. We confirm that HLA-G-specifically inhibits the ILT2+ CD8+ T cell and ILT2+ NK cell subsets but not ILT2-negative ones. By blocking HLA-G/ILT2 interaction using an anti-ILT2 antibody we restored the cytotoxicity level, corroborating the specific inhibition of HLA-G1. We believe that our methodology enables to investigate HLA-G immune functions easily and finely towards other immune cell lineages or expressing other receptors, and might be applied in several pathological contexts, such as cancer and transplantation.

[Impact of neoadjuvant chemotherapy on the peri-operative morbidity of radical cystectomy for muscle invasive bladder cancer]. / Impact de la chimiothérapie néoadjuvante sur la morbidité péri-opératoire de la cystectomie pour tumeur de vessie infiltrant le muscle.

INTRODUCTION: Platinum-based neoadjvant chemotherapy (NAC) before radical cystectomy (RC) is the gold standard in the treatment of muscle invasive bladder cancer (MIBC). We aimed to compare the peri-operative morbidity in patients treated by NAC then RC and patients having RC alone. METHODS: Between 1st January 2008 and 31st December 2015, we retrospectively included consecutive patients undergoing RC for MIBC in 2centers. We collected clinical, pathological and peri-operative data (30day post operative complications according to the Clavien-Dindo score, delayed complications, pathological results). Patients treated by NAC (NAC-RC group) before RC were compared to patients performing RC alone. The NAC-RC group received 1 to 6cycle of high-dose MVAC, MVAC or gemcitabine-cisplatine chemotherapy. Logistic regression identified independant factors of peri-operative complications. RESULTS: We included 199 patients: 48in the NAC-RC group and 151in the RC group. Complications rate was 73.9% in the NAC-RC group versus 73.8% in the RC group (P=1.0). In multivariate analyses, only the Charlson score was associated with an increased risk of peri-operative complications (P=0.05). PT0 tumour rate was significantly higher in the NAC-CR group (50% vs 7%, P<0.001). CONCLUSION: NAC does not increase the peri-operative morbidity of the RC. Patients' pre operative comorbidities is the main risk factor for peri-operative complications.

Endothelial Cells Exposed to Fluid Shear Stress Support Diffusion Based Maturation of Adult Neural Progenitor Cells.

INTRODUCTION: The neural stem cell (NSC) niche is a highly complex cellular and biochemical milieu supporting proliferating NSCs and neural progenitor cells (NPCs) with close apposition to the vasculature, primarily comprised of endothelial cells (ECs). Current in vitro models of the niche incorporate EC-derived factors, but do not reflect the physiologically relevant hemodynamic state of the ECs or the spatial resolution observed between cells within the niche. METHODS: In this work, we developed a novel in vitro model of the niche that (1) incorporates ECs cultured with fluid shear stress and (2) fosters paracrine cytokine gradients between ECs and NSCs in a spatiotemporal configuration mimicking the cytoarchitecture of the subventricular niche. A modified cone and plate viscometer was used to generate a shear stress of 10 dynes cm-2 for ECs cultured on a membrane, while statically cultured NPCs are 10 or 1000 µm below the ECs. RESULTS: NPCs cultured within 10 µm of dynamic ECs exhibit increased PSA-NCAM+ and OLIG2+ cells compared to progenitors in all other culture regimes and the hemodynamic EC phenotype results in distinct progeny phenotypes. This co-culture regime yields greater release of pro-neurogenic factors, suggesting a potential mechanism for the observed progenitor maturation. CONCLUSIONS: Based on these results, models incorporating ECs exposed to shear stress allow for paracrine signaling gradients and regulate NPC lineage progression with appropriate niche spatial resolution occurring at 10 µm. This model could be used to evaluate cellular or pharmacological interactions within the healthy, diseased, or aged brain.

The Pararectus approach provides secure access to the deep circumflex iliac vessel for harvest of a large sized and vascularized segment of the iliac crest.

BACKGROUND: The feasibility of harvesting a vascularized iliac crest utilizing the Pararectus approach was assessed in cadavers and then this new technique was implemented in a clinical case. METHODS: Bilaterally in five cadavers the branches of both external iliac arteries were injected with colored silicone to assess their position to each other and to harvest a bone graft vascularized by the deep circumflex iliac artery (DCIA) through the Pararectus approach. This technique was implemented in a 68-years-old female patient, initially admitted to a level-I-trauma center after sustaining multiple injuries by falling from great height. For definitive treatment of a severely contaminated medially open (Gustilo-Anderson Type 3A) calcaneal luxation fracture (Sanders type IIIBC) in this patient a vascularized iliac crest autograft harvest by the Pararectus approach was used for reconstructive surgery. RESULTS: The DCIA and the deep inferior epigastric vessels (DIEV: vascularizing the rectus abdominis muscle and main pedicle of the inferiorly based rectus abdominis myocutaneous flap) are very close on the lateral and medial border of the external iliac artery, respectively. As a consequence, the retrograde dissection of the DIEV towards the DCIA through the Pararectus approach made the dissection of the vascularized iliac crest more amenable, preserving both the lateral femoral cutaneous and the genitofemoral nerves. Four months after the surgery the patient was able to fully weight-bear in orthopedic shoes. Radiographs and CT scans showed correct hind foot alignment and bony integration of the vascularized iliac crest graft into the residual calcaneal body. CONCLUSION: The Pararectus approach allowed for secure collection of large vascularized iliac grafts. The presented technique was successful as a salvage procedure in a clinical case with substantial bone loss after an open calcaneal fracture.

[Acute scaphoid fractures : Management under consideration of the new S3-level guideline]. / Die frische Skaphoidfraktur : Management unter Berücksichtigung der neuen S3-Leitlinie.

BACKGROUND: Scaphoid fractures represent the most common carpal fractures and are often problematic and frequently lead to nonunion with osteoarthritis and collapse of the wrist. The reasons for the nonunion are manifold. Therefore, the main goal of diagnosis and therapy of acute fractures is to achieve bony union and to restore the anatomic shape of the scaphoid. In the long run, only this can preserve the normal function of the wrist. METHODOLOGY: The given recommendations are based on the new S3-level guideline of the AWMF (Association of the Scientific Medical Societies). This guideline was established with involvement of all relevant medical societies based on a comprehensive and systematic review of the literature and after a process of formal consent. The focus of the guideline is recommendations regarding diagnosis and therapy of acute scaphoid fractures. MAIN STATEMENTS: After careful clinical examination consequent imaging must be performed, starting with X­rays in three standard projections. Computed tomography is indispensable for proof of a fracture and for therapy planning. The classification of Herbert and Krimmer is based on the CT under special consideration of instability and displacement of the fracture. Thus, indication for operative and non-operative treatment is mainly CT-dependent. Non-operative treatment may be indicated only for stable fractures (type A). However, operative treatment is strongly recommended for all unstable fractures (type B). For fixation, double-threaded headless screws are preferred. The operative technique depends on the fracture morphology. CONCLUSION: Diagnosis and therapy of acute scaphoid fractures are primarily aimed at the prevention of nonunion and arthritic carpal collapse with painful impairment of the wrist function. To achieve this, the S3-level guideline contains explicit recommendations.

Why should the anesthesiologist evaluate nutritional status?

BACKGROUND: The anesthesiologist's involvement in perioperative medicine has significantly changed. In order to identify patients at risks of perioperative complications, the anesthesiologist has to consider, amongst others, screening and management of undernutrition. For this purpose knowledge of prevalence and risk factors, along with screening tools and guidelines for an adapted nutritional management and outcomes of renutrition are mandatory. The present review intends to provide these tools to the Anesthesiologists. METHOD: We conduct a literature review in Pubmed, Direct Science and Cochrane Library without limit of time related to undernutrition in the perioperative period. RESULTS: Undernutrition is common in surgical patients. Undernutrition is associated with an increase of morbidity, mortality, length of hospital stay and costs. Undernutrition could probably be detected during the anesthetic consultation with simple and rapid tests, such as SNAQ, MST, MUST and NRS-2002. Nevertheless, further studies are needed to validate such tests in surgical patients. Waiting for these results, we prefer MUST. The implementation of nutritional support recommendations would reduce postoperative complications. CONCLUSION: The anesthesiologist could play an important role in undernutrition screening and its management in order to reduce perioperative morbidity.

[Ultrasound appearance of the area of uterine closure in asymptomatic patients at 48 hours of uneventful cesarean section]. / Aspect échographique de la zone d'hystérorraphie chez des patientes asymptomatiques à j2 d'une césarienne non compliquée.

OBJECTIVE: It seeks to assess the appearance of the hysterorrhaphy area and seeks hematoma in asymptomatic patients at 48hours of their cesarean. METHOD: It is common to see, ultrasound or CT scan, collection of images next to the hysterorrhaphy area in symptomatic patients after cesarean. Their interpretation remains difficult which led us to propose a prospective study looking for an evocative image collection or hematoma in asymptomatic patients at 48hours of their cesarean. It was directed suprapubic and transvaginal pelvic ultrasound with study area hysterorrhaphy and inter-uterine bladder space. RESULTS: The suprapubic ultrasound examination was performed in 31 asymptomatic patients after collecting their written consent. Twenty-eight patients also received an endovaginal examination. The studied area was easily identified by visualizing the path of hysterotomy and hyperechoic aspect of the hysterorrhaphy. In 28 cases there were no abnormal image in front of the hysterorrhaphy area. In 3 cases, an evocative image of a haematic collection was displayed and measured a maximum of only 49mm long axis with a weak Doppler signal. The exam was very well tolerated by patients, especially by transvaginal route. Also the duration of ultrasound never exceeded 58seconds and remained fastest vaginally. CONCLUSION: This preliminary work to a prospective double cohort (symptomatic patients and asymptomatic patients) has clarified the technique to use and focus in the search for a collection next to the hysterorrhaphy area. Ultrasound examination postoperatively, especially vaginally, is very fast, well tolerated with satisfactory image quality. Finally in this cohort of asymptomatic patients, it was very unusual for a collection, confirming the credit to be given to this type of image in case of symptoms after cesarean.

[Physical restraint and procedure]. / Procédures et contention physique.

The widespread practice of physical restraint of the elderly has used in most case in order to protect elders against injuries after falls or to manage behaviour agitation during delirium for example. However, "protect" isn't correct because of the adverse effects have been reported as falls increase, pressures sores, depression, aggression and death. In fact, efficacy of restraints for safeguarding patients from injury has not been demonstrated clinically. This paper reviews the current medico-legal knowledge regarding physical restraint use in this frail population and suggests some considerations about ethical practice and procedure evaluation.

[Soft tissue protective and minimally invasive osteosynthesis for metacarpal fractures II-V]. / Weichteilschonende minimal-invasive osteosynthesen bei mittelhandfrakturen II-V.

OBJECTIVES: Soft tissue protection, closed reduction or short open reconstruction of length, rotation and articulation of metacarpals. Aftercare: early active exercises protected by additive orthesis. INDICATIONS: Closed or grade 1 open fractures with significant dislocation, deviation of rotation or loss of length. Fractures of the metacarpal, metaphyseal and extensive oblique or spiral fractures. Intra-articular fractures of the distal metacarpal that can be reduced without a step in articular surface. Proximal partial articular fractures that can be reduced without a step in articular surface in the mini-open technique. CONTRAINDICATIONS: Grade 2 and 3 open fractures, extensive bending fractures in the middle third and absence of the palmar bony restraint. Multifragmentary proximal and distal metaphyseal fractures that cannot be reduced by closed methods. Intra-articular fractures that cannot be reduced without a step in articular surface. SURGICAL TECHNIQUE: Intramedullary antegrade or percutaneous K-wires or mini-open repair screw/K-wire osteosynthesis. POSTOPERATIVE MANAGEMENT: Two or three finger forearm cast for about 3-4 days, subsequent metacarpal orthesis, an integrated hard cast Longuette (Combicast) SoftCast™ is preferred beginning with active and passive exercises of the fingers. RESULTS: In this retrospective study we analyzed metacarpal (MC) fractures that were treated with minimally invasive osteosynthesis during the period 2009-2010 and 65 patients (mean age 34.8 years, female/male 13/52) with 75 metacarpal fractures were enrolled. Fractures affected MC-2 (n=9), MC-3 (n=5), MC-4 (n=15) and MC-5 (n=46). Removal of implant was performed after 6-12 weeks in 44 patients. All fractures except one showed bony healing in x-ray. At 2-months follow-up 61 patients could be evaluated and at 27-months (15-37) follow-up 34 patients could be evaluated according to the DASH score. Median DASH score results were 16 points (SD 49, n = 61) after 2 months and median DASH score results were 5 points (SD 23, n = 34) after 27 months (15-37). Range of motion was limited in 6 patients after 8 weeks (range 6-12 weeks) with a deficit in flexion of finger to distal palmar crease of 1.0 cm (range 0.5-1.5 cm), 2 patients showed a deficit in finger extension of 10° in the metacarpophalangeal joint. One patient showed restricted finger extension of 15° in the proximal phalangeal joint after tendon rupture and tendon reconstruction. Complications were observed, such as circumscribed redness in two patients at the entry point of k-wires which was managed by early removal of the implant. Perforation of the k-wire occurred in one patient with subcapital and diaphyseal fracture and was managed by plate osteosynthesis. One diaphyseal transverse refracture healed after plate osteosynthesis, three circumscribed cases of paresthesia occurred, one at the entry point of the K-wires and two at the level of fracture.

[Minimally invasive osteosynthesis. : even in talus fractures?]. / Minimal-invasive osteosynthese : auch bei talusfrakturen?

OBJECTIVE: Minimally invasive osteosynthesis of talar fractures. INDICATIONS: Minimally displaced fractures of the lateral process of the talus and talar neck fractures type 1 according to Hawkins classification. CONTRAINDICATIONS: Dislocated peripheral fractures. Displaced fractures of the talar neck or body. SURGICAL TECHNIQUE: For factures of the lateral process of the talus: short incision of skin over the lateral process of the talus. Gentle preparation and contact with the bone with scissors. Fragment reposition using a dentist's hook and Kirschner wire in a joy-stick technique under C-arm imaging. Stabilization with a miniscrew. For talar neck fracture Hawkins type 1: short incision of skin ventromedially and ventrolaterally. Blunt preparation of soft tissue and safe bone contact. Introduction of one small-fragment corticalis screw both medially and laterally under C-arm imaging. As an alternative, cannulated screws can also be used. POSTOPERATIVE MANAGEMENT: For fractures of the lateral process of the talus: postoperative protection in an ankle splint (air cast, gel cast) for 4 weeks. During this time moderate weight bearing is possible. For talar neck fractures Hawkins type 1: physiotherapy and only floor contact for 6 weeks. RESULTS: From January 1996 to December 2002, 44 talar fractures were operatively treated in our department. Six patients had talar neck fractures type 1 according the Hawkins classification and 3 patients showed fractures of the lateral process of the talus. From those injuries, 3 Hawkins type 1 fractures and 2 fractures of the lateral process were stabilized using minimally invasive osteosynthesis. The clinical outcomes were assessed using the Ankle Hindfoot Scale of the American Orthopedic Foot and Ankle Society. Both groups reached good cosmetic and functional results. We did not observe any avascular talar necrosis or nonunions in the two groups.