Application of damage control orthopedics to combat-related hand injuries.

The purpose of this report was to analyze sequential management of patients with combat-related hand injuries in the Kabul International Airport Combat Support Hospital and to identify principles of hand damage control orthopedics (DCO). A retrospective study was conducted using the French Opex data system that included all the patients who received sequential treatment for combat-related hand injuries from 2009 to 2013. Demographics, mechanism, injury pattern, reasons for DCO application and surgical procedures performed during initial and definitive treatment were described. Forty-one patients were included: 14 French soldiers and 27 Afghan patients. Explosive devices were the most common injury mechanism. There were multiple reasons for DCO application in 20 cases. Debridement, skeletal fixation by pinning or splinting, and delayed primary closure were the main emergent procedures. Primary and secondary treatment data did not differ between French and Afghan patients. Although Afghan patients were fully treated on site, the time to secondary procedures was three time higher in this group because of intense operational activity during the period study. The functional outcome was only evaluated in French soldiers who were treated definitely in France. Hand DCO may be required in various situations encountered in both military and civilian settings: polytrauma; delayed transfer to hand specialist; complex high-energy injuries due to firearms or explosive devices. The basic elements of this specific surgical tactic are meticulous debridement, detailed wound assessment and temporary skin coverage.

Vascularised fibula or induced membrane to treat congenital pseudarthrosis of the Tibia: A multicentre study of 18 patients with a mean 9.5-year follow-up.

BACKGROUND: The objective of this study was to compare outcomes of two surgical techniques used to treat congenital pseudarthrosis of the tibia (CPT), the induced membrane technique (IM) and the transfer of the contralateral vascularised fibula (VF). HYPOTHESIS: The IM technique produces similar outcomes to those of VF grafting in terms of healing and function, while being simpler and having a lower complication rate. MATERIAL AND METHOD: This retrospective multicentre study included 18 patients with a mean age of 2.8 years at surgery. Among them, 11 had neurofibromatosis type 1 (NF1). The IM technique was used in 10 patients and VF grafting in 8 patients. Mean follow-up was 9.5 years (range: 5-15 years). RESULTS: The two groups showed no significant differences for healing or the occurrence of complications such as limb length discrepancy and residual malalignment. Two patients required amputation, one in each group. The mean number of surgical procedures per patient was 4.7 in the IM group and 5 in the VF group. DISCUSSION: Outcomes are similar with the two techniques. Although VF grafting theoretically involves a single stage, the mean number of surgical procedures was not lower than after the IM technique. The IM technique was associated with lower risks of complications and residual donor site abnormalities. Regardless of the reconstruction technique, the quality of the initial bone resection and internal fixation, particularly regarding alignment, is of the utmost importance. LEVEL OF EVIDENCE: IV, comparative retrospective study.

Peritrapezial osteoarthritis: Inter- and intraobserver reliability of the Allieu classification.

The Allieu classification takes into consideration the distal and proximal joints of the trapezium. Trapeziometacarpal (TMC) joint arthritis, TMC joint instability (TMI) and scapho-trapezio-trapezoid (STT) joint arthritis are considered independently, which better corresponds to the anatomical examinations. The aim of the study was to evaluate the inter- and intraobserver reliability of the Allieu classification of the peritrapezial arthritis. This was a prospective, single-center study performed from May to September 2016 with 30 cases of primary thumb osteoarthritis. Five raters scored the X-rays twice. In the Allieu classification, TMC arthritis is scored as "0" when the TMC joint is normal, "1" when the TMC joint space is <50% narrowed, "2" when the TMC joint space is >50% narrowed, "3" when the joint space is loose with advanced degenerative changes. TMI is scored as "0" for reducible subluxation, painful and unstable joint, "1" for advanced reducible subluxation, "2" for chronic subluxation <1/3 of the surface, "3" for chronic subluxation >1/3 of the surface. STT joint arthritis is scored as "0" for normal joint space, "1" for joint space narrowing <50%, "2" for important joint space narrowing and "3" for advanced degenerative changes with sclerotic subchondral bone changes. Inter- and intraobserver reliability was assessed using the weighted Cohen's kappa coefficient. Additional analyses were undertaken to determine the intraclass correlation coefficient (ICC) for the overall raters. The interobserver reliability was "moderate" to "substantial" for the TMC arthritis; "fair" to "substantial" for STT arthritis and "fair" to "substantial" for TMI. The intraobserver reliability was "moderate" to "excellent" for TMC arthritis (2 "excellent", 2 "substantial", 1 "moderate"); "fair" to "excellent" for the STT (1 "excellent", 2 "substantial", 1 "moderate", 1 "fair") and "fair" to "excellent" for the TMI (1 "excellent", 2 "substantial", 1 "moderate", 1 "fair"). The worst reliability, either for intra- or interobserver, was for TMI. The ICC for TMC arthritis was 0.67 (95%CI, 0.28-0.83); for STT it was 0.47 (95%CI, 0.15-0.66) and for TMI it was 0.30 (95%CI, 0.23-0.70), which is "fair". This study confirms a large variation in X-ray staging for peritrapezial arthritis. It shows that the Allieu classification is moderately reliable. However, the interobserver reliability was better for evaluating the TMC than the STT and worse for TMI. The classification for TMC and STT is simple to apply, based principally on the joint narrowing. The intraobserver is better than the interobserver reliability.

[Clubfoot treatment: Implementation of the Ponseti method in emerging countries]. / Traitement du pied bot varus équin idiopathique Mise en place de la méthode Ponseti dans un pays émergent.

Idiopathic clubfoot is one of the most frequent congenital deformities throughout the world. The Ponseti method is the gold standard for its treatment. This simple, low-cost method is very effective and very appropriate for countries with resource-limited or otherwise precarious health services. It is based on correction of the deformity by successive castings associated with a percutaneous Achilles tenotomy and then foot abduction bracing to maintain the correction. The Ponseti method is now well implemented in most emerging countries, largely due to internet development, but some barriers still limit its diffusion. This study aims to determine the principal barriers, to suggest some improvements, and to stress the essential points of its effective utilization by non-physicians.

Trapeziometacarpal joint dislocation complicated by a trapezium fracture: A case report and literature review.

The authors report and discuss the management of a 25-year-old male patient with a trapeziometacarpal joint dislocation complicated by a trapezium fracture. This injury combination is rare with only reported 15 cases. After closed reduction resulted in dorsal instability, anatomical reduction of the trapezium fracture and internal screw fixation were performed using an open approach. This fixation stabilized the joint but was fragile due to the small fragment size. For this reason, ligament reconstruction using half of the flexor carpi radialis tendon was added. At the last follow-up, 16 months later, the trapeziometacarpal joint was stable with a normal range of motion, but the patient had slight pain during physical effort and decreased pinch strength.