Benefits of WALANT in palliative upper limb surgery after nerve injury.

Wide-Awake Local Anesthesia No Tourniquet (WALANT) may be a satisfactory anesthesia alternative for the management of upper limb peripheral nerve palsy sequelae. The main advantages are the possibility of active patient cooperation through intraoperative active mobilization, comfort and cost reduction. The legislation about WALANT in France remains unclear; the modalities of lidocaine epinephrine injection should be redefined. For palliative upper limb surgery, WALANT allows the surgeon to adjust the tension on the tendon transfer intraoperatively. Level 1 studies are needed to evaluate the effectiveness of WALANT relative to standard anesthesia techniques (regional/general anesthesia).

Postgraduate training in surgery: From theory to practice.

INTRODUCTION: Postgraduate training is a time-honored entity, the goal of which was to develop and ensure the acquisition of new medical knowledge for the medical profession. MATERIAL AND METHODS: The main goal of this retrospective study is to analyze the current situation of postgraduate training in surgical disciplines within the framework of the French Universities. We studied the legal texts found in the LéxisNéxis® and Légifrance® sites up until December 1, 2018; references were sought from the Web of Science repository. RESULTS: Postgraduate training in France is mandatory from the legal point of view. Currently there are two possibilities for validation of postgraduate training: either through a recognized continuing professional development (CPD) organization controlled by the National Agency of Continuing Professional Development (NACPD), or by asking for certification through an official accreditation council (AC) (one exists for each surgical specialty), controlled by the High Health Authority that can automatically provide the equivalence of passing through the NACPD organization. DISCUSSION: The continuing education process remains complex. It could well be modified in the near future by the creation of a new certification procedure. With regard to surgical education, whether it concerns the CPD or the accreditation process, the goal is to decrease patient risk and to be an integral part of the overall policy to decrease health care costs. The role of professional national counsels will be more and more important; this is an advantage for each of the surgical specialties. Nonetheless, from the regulatory viewpoint, the decree concerning the role of National Professional Councils has not yet been published in the Journal Officiel de la République Française (French Republic official journal) at the time of writing. CONCLUSIONS: Currently two systems are available for surgeons to comply with the 2016 legislative obligation of continuing education: CPD which is run by the NACPD, and the accreditation process, run by an AC and controlled by the HAS; in the first instance, surgeons can ask for reimbursement from the NACPD and in the second, request that the National Health Insurance Fund for Salaried Employees cover a portion of the litigation insurance premium. LEVEL OF EVIDENCE: Retrospective study: level of evidence IV.

[Research in clinical epidemiology: which rules should be applied?]. / Recherche en épidémiologie clinique: quelles règles appliquer?

The adaptation of the European directive 2001/20/CE on clinical drug trials was the opportunity for a profound reform of the legislative framework on biomedical research in France. Within the main innovations, the distinction between the three broad research categories was retained: biomedical research, research on standard care, and non-interventional research. These changes have rendered the legislative arsenal of research more complex, and therefore these changes should be reviewed. This article presents how the 2007 French healthcare research regulations can be applied. Briefly, four questions should be asked before research is undertaken: (1) does the study require a specific procedure on a person (intervention or investigation)? (2) Does it use material from the human body that will be preserved or discarded? (3) Does it require processing personal patient data? (4) Does it include genetic data? Researchers are expecting a simplification of procedures with the new regulations. This objective has been partially met, but a certain number of questions remain unanswered, particularly in the field of epidemiology.

Epidemiology of traumatic upper limb amputations.

INTRODUCTION: While published data on functional outcomes after upper limb amputations are plentiful, epidemiology data are relatively rare. This led us to performing an epidemiology study of traumatic upper limb amputations at our facility. MATERIAL AND METHODS: This retrospective study spanned a 10-year period of cases seen at the SOS Main (Hand emergency center) of the Nancy University Hospital in France. Patients who suffered traumatic amputation of the upper limb were identified and divided into two groups: replantation and surgical amputation. All anatomical amputation levels were retained. Non-traumatic amputations were excluded. Epidemiology data (sex, age, dominant side, injured side) was collected along with the specific anatomical level of the injury, the injury mechanism and whether it was work-related. We also looked at the success rate of microsurgery and whether multi-finger amputations were partial or complete. In parallel, the annual incidence of amputations seen at the SOS Main over this period was calculated. RESULTS: Over the 10-year period, 1715 traumatic upper-limb amputations were identified, which was 3% of all cases seen at the SOS Main. Most of the cases involved middle-aged men. Revascularization was attempted in one-third of cases and microsurgery was successful in 70% of cases. The surgical amputation group consisted of 1132 patients with a mean age of 59 years, while the replantation group consisted of 583 patients with a mean age of 48 years. The primary mechanism of injury was a table saw. DISCUSSION: This injury, which must be addressed urgently, is not very common in everyday practice. This is contrary to lower limb amputations, which are more common and occur in the context of micro- and macroangiopathy in older patients. The success rate of microsurgery in this cohort must be placed in the context of age, amputation level and mechanism. The functional outcomes are not always as good as the vascular outcomes. This data is invaluable as it fills a gap in our knowledge about amputations. LEVEL OF EVIDENCE: IV.

No-go decision: A newly identified adverse event in orthopaedic surgery - causes and medico-legal implications.

BACKGROUND: No-go designates a decision not to perform surgery when it becomes apparent that safety and/or feasibility requirements are not met. No-go decisions can occur at any time between patient admission to a hospital department and immediately before the first incision. The primary objective of this study was to assess the causes of no-go decisions reported as healthcare-associated adverse events (HAAEs). HYPOTHESIS: Most no-go decisions in orthopaedic surgery are related to problems with medical devices. MATERIAL AND METHODS: A preliminary retrospective study assessed HAAEs reported over the 1-year period from 1st October 2014 to 30th September 2015, using the risk-management tool ALARM. A prospective survey was then performed by emailing a 15-item questionnaire to the 1828 members of Orthorisq (the French orthopaedic surgeon accreditation agency). Responses were either yes/no or open. Statistical comparisons were performed, using the paired Wilcoxon signed-rank test to estimate p values. RESULTS: Among reported HAAEs, 5.6% were no-go decisions. Of the 101 reported no-go decisions, 43.5% and 45.2% were due to problems with managing implantable medical devices in the retrospective and prospective assessments, respectively. In over 85% of cases, surgery was cancelled or postponed. Over half the no-go decisions were associated with unnecessary anaesthesia. Checklist completion was performed in only half the cases and was not associated with no-go decisions (p>0.8). DISCUSSION: This study provides descriptive data on no-go decisions in orthopaedic surgery. Healthcare professionals use many methods to enhance patient safety by preventing adverse events or diminishing their impact. Errors in managing implantable medical devices are the leading cause of no-go decisions. The current checklist is not appropriate for managing implantable medical devices in orthopaedic surgery, in part because it does not include checking devices upon receipt. Before surgery, patients should be informed of the risk of a no-go decision, since unnecessary anaesthesia occurs in over half the cases. LEVEL OF EVIDENCE: IV, prospective study.

[Market licensing authorisation: medico-legal impact]. / Recommandations et autorisation de mise sur le marché: quel impact médico-légal?

Respecting market licensing authorisation recommendations is a prudent and preventive policy in respect of professional liability, but is not sufficient to avoid all of the doctor's responsibility. Conversely, not respecting the recommendations or off-indication prescribing does not necessarily make the practitioner liable. Although neither the recommendations, nor the market licensing authorisation are legally binding for the cardiologist, they can be invoked during a lawsuit. For this reason it seemed appropriate for us to study the medico-legal impact.

[Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation: a review of 28 cases]. / Greffe de chondrocytes autologues dans le traitement des pertes de substance condylienne du genou: bilan de 28 implantations.

PURPOSE OF THE STUDY: The knee has little capacity for spontaneous regeneration of deep cartilage defects. In 1999, the French Society of Arthroscopy initiated a multicentric clinical trial on autologous chondrocyte transplantation using the technique described by Brittberg and Peterson. The protocol of this prospective study was validated by the ethics committee and all patients provided the informed consent for participation. MATERIAL AND METHODS: Patients underwent surgery in seven hospitals: 28 patients (7 female, 21 male, mean age 28 years, age range 18-45 years). The underlying condition was: osteochondritis (n=14), isolated posttraumatic chondropathy (n=8), chondropathy plus ACL tear (n=6). All patients presented deep condylar cartilage defects (ICRS grades 3 and 4). Mean surface area involved after debridement was 490 mm2 (range 150-1050 mm2). Patients were reviewed two years at least after transplantation for functional assessment and an MRI performed 2 to 3 years after transplantation. Control arthroscopy was also performed in 13 patients with biopsy for histology and immunohistochemistry for 10. RESULTS: Twenty-six patients were reviewed with more than two years follow-up (mean 2 years 9 months). There were no general complications; three patients presented a partial avulsion of the autograft treated arthroscopically and one arthrolysis was performed at six months. Function was improved in all patients but four, but pain persisted in one patient. The mean ICRS score improved from 41 points (19-55 points) to 74 points (54-86 points), for an 80% gain. Follow-up MRI was available for 16 knees: the graft was hypertrophied in 11, at level in 3 and insufficient in 2; marginal integration was good in 10 knees and fair in 6. Items of marginal and subchondral integration had a very high positive predictive value for good clinical outcome. The arthroscopic score was nearly normal (range 8-11) in 8 knees and abnormal (range 4-7) in 5. The Knutsen histological groups according to richness of hyaline cartilage were: group 1 (>60%) (n=1); group 2 (>40%) (n=3), group 3 (<40%) n(=4) and group 4 (bone or fibrous tissue) (n=1). The function scores (r=0.80) and the MRI scores (r=0.76) were correlated with the arthroscopy scores. There was no correlation between the histological findings but the sample size was too small for meaningful analysis. DISCUSSION: The clinical results demonstrate an improvement in more than 80% of knees, findings similar to earlier reports. The arthroscopic and histological results were equivalent to those reported by Knutsen, but less satisfactory than those reported by Bentley or Peterson. Cell injections under a periosteal patch constitute the first generation of autologous chondrocyte grafts. Resorbable matrices loaded with chondrocytes before implantation are under development and have provided promising early results.

Advantages of external hybrid fixators for treating Schatzker V-VI tibial plateau fractures: A retrospective study of 40 cases.

INTRODUCTION: Proximal tibia fractures make up 1% of all fractures in adults. The fractures classified as Schatzker V and VI fractures can compromise knee structure and function. They are challenging to treat and often have complications. While plate fixation is the gold standard, the resulting infection rate has led us to favor external hybrid fixation. The aims of this study were to assess the radiographic and functional outcomes along with the complication rate when using this method and to compare them to historical plate fixation data. MATERIAL AND METHODS: This was a retrospective study of 40 patients. The complications, quality of reduction, IKS, Lysholm and Rasmussen functional scores at the latest follow-up and factors affecting the functional outcome were evaluated. These parameters were compared to published results from plate fixation studies. RESULTS: The deep infection rate was 2.5%. The union rate was 80%. Satisfactory reduction was obtained in 70% of cases; however, 52% of patients had malunion. The mean IKS score was 73.74, the mean Rasmussen score was 22.85 and the mean Lysholm score was 75.53. Age, reduction at latest follow-up, mechanical axis and anteroposterior laxity had a significant effect on the functional outcome. DISCUSSION: Despite the malunion rate being higher than other studies, the functional outcomes were nearly identical based on the variables measured. There are several advantages associated with using a hybrid external fixator: shorter operative time, less bleeding, shorter hospital stays and lower infection rate. CONCLUSION: Hybrid external fixation is a reliable fracture fixation method that leads to satisfactory functional outcomes, while reducing the infection rate and allowing arthroplasty to be performed in the future if needed.

The concept of a waiting period for preoperative patient consent: Prospective study of 51 shoulder arthroscopy cases.

INTRODUCTION: The French Code of Public Health (CSP) does not explicitly require that patients should be given a certain amount of time to think about a procedure, except for cosmetic surgery, where 15 days is required (Art. L 6322-2 CSP). We hypothesized that patients require a waiting period during their decision-making process for scheduled shoulder arthroscopy procedure. MATERIALS AND METHODS: This prospective observational study of 51 patients analysed the concept of a waiting period based on a 10-item questionnaire. A comparative statistical approach was used and the P values were calculated using a paired Wilcoxon rank-sum test. RESULTS: Of the 51 patients, 42 (82%) rejected the concept of a waiting period before the procedure and 37 patients (73%) did not want a mandatory waiting period imposed by law. DISCUSSION: This study looked at the decision-making process during scheduled orthopaedic surgery and differentiated between the conscious and unconscious approach corresponding to an active and passive waiting period. A waiting period does not allow patients to make a conceptually deliberative decision that conforms to the criteria defined by the French Health Authority. This study rejects the need for a mandatory waiting period imposed on surgeons and patients as it does not integrate itself into the informative model of ethical decision-making for scheduled shoulder arthroscopy. TYPE OF STUDY: Prospective, observational; level of evidence IV.

[Forensic examination of sexual assault victims: Medical aspects and associations with the legal outcomes]. / Examen médicolégal des victimes d'agression sexuelle : caractéristiques et liens avec les suites judiciaires.

OBJECTIVES: To describe the medical and legal characteristics of sexual assault victims and to highlight which aspects of the medical examination may be associated with a conviction of the alleged offender. METHODS: This study included all women who consulted to the center for the victims of sexual assault in Nancy between 2008 and 2012 and who filed a complaint. Associations were evaluated with a logistic regression trying to explain the presence of a conviction at the end of the legal proceeding. RESULTS: Three hundred seventy-six victims were included. Following aspects were associated with a reduced probability of conviction: the use of psychoactive substances, the prescription of an antiretroviral therapy and the presence of more than one assailant. The prescription of pain killers were contrarily related to the conviction of an assailant. CONCLUSION: A detailed description, an interpretation of the physical injuries and the prescription of toxicological tests if needed are decisive in the outcome of the legal proceedings of victims of sexual assault. The education of populations at risk and the accompanying of the victims can reduce the delay of care and optimize the collection of evidence.

[Shoulder arthroscopy: setting, portals and normal exploration]. / Arthroscopie de l'épaule, installation, voies d'abord et exploration normale.

Arthroscopy has been established as a valuable technique in diagnosis and treatment of the injured and deseased shoulder. Arthroscopy is not a new diagnostic tool but offers new approaches to the surgical treatment of shoulder pathology. Shoulder arthroscopy is usally performed under general anesthesia or/with scalene block. The patient is positioned in opposite lateral decubitus position or in beach chair position. Diagnostic arthroscopic is initiated with insertion of the arthroscope from the posterior portal into the gleno humeral joint. Inspection should be organized systematic visualization of the entire joint (articular surfaces of the glenoid and humeral head, glenoid labrum, long head of the biceps tendon, sub scapularis tendon, axillary pouch, capsular ligaments, synovial membrane). Then endoscopic visualization of the subacromail space is a valuable and essential adjunct to the gleno humeral arthroscopy (impingement syndrome, rotator cuff tears, calcific tendinitis, acromiocalvicular joint disorders).

Patient information in orthopedic and trauma surgery. Fundamental knowledge, legal aspects and practical recommendations.

Providing information to surgery patients is a form of health-care governed by clearly defined therapeutic and medicolegal rules, and in particular in France by the Act of March 4, 2002 and the Code of Good Practice. The patient's right to information is implemented in a face-to-face consultation, which should be fully codified, and in a specific clinical examination, followed by information regarding the affected organ, pathology, treatment options, possible surgery, and the preconditions, risks and results associated with the procedure. Information should be personalized and as complete as possible, communicating the state of knowledge as validated by scientific societies and medical institutions. State of the art technology (dedicated website, on-line information suites, etc.) is indispensable but needs to be mastered and to adhere to the guidelines of the Council of the National Order of Medicine. Information traceability, the retraction period and proof of content of the information are essential. A signed document delivered in an informative atmosphere optimizes the exercise. Patient information is an ethical and medicolegal obligation, but above all is the expression and demonstration of the health-care potential of the practitioner and our contribution to reducing the information gap, reinforcing the cement holding our society together.

Developments in imaging methods used in hip arthroplasty: A diagnostic algorithm.

BACKGROUND: Several imaging modalities can be used to diagnose complications of hip prosthesis placement. Despite progress in these imaging techniques, there are, as yet, no guidelines as to their respective indications. METHODS: We formed a panel of experts in fields related to prosthesis imaging (radiology, nuclear medicine, orthopedic surgery) and conducted a review of the literature to determine the value of each modality for diagnosing complications following hip replacement. RESULTS: Few recent studies have investigated the benefits related to the use of the latest technical developments, and studies comparing different methods are extremely rare. CONCLUSIONS: We have developed a diagnostic tree based on the characteristics of each imaging technique and recommend its use. Computed topography was found to be the most versatile and cost-effective imaging solution and therefore a key tool for diagnosing the complications of hip replacement surgery.

[Requests for access to medical files at the Nancy University Hospital Center]. / Evaluation des demandes d'accès au dossier medical au CHU de Nancy.

OBJECTIVE: Law 2002-303 of March 04, 2002, authorizes patients to have direct access to their medical record, without requiring a physician to serve as interme-diary. The aim of this study was to characterize these requests for a 23-month period. METHOD: A database was created to record information about these requests. The descriptive and quantitative analysis here covers 23 months. RESULTS: There were 942 requests in all, 64.5% by patients themselves and 18.5% by their heirs or assignees. The mean age of the patients seeking access to their medical file was 53 years, with a slight majority of men. Heirs and assignees av-eraged 49 years of age and were generally women. Thirty percent of them reported wanting some additional information, while 51% requested a copy of the entire file. Only 5.8% asked for a physician to help them understand the file, although that was systematically offered. CONCLUSION: Patients' new legal rights to direct access to their medical files imply that physicians will modify the way they maintain these files.

Arthroscopy and obesity.

UNLABELLED: Obesity is a major public health issue, as incidence is rising in all developed countries, although the proportion is lower in Europe than in the U.S. Over and above the metabolic consequences and increased risk of diabetes, cardiovascular pathology and certain forms of cancer, the present study focuses on osteoarticular risk, and in particular on pathologies manageable by arthroscopy. It also analyzes results and complications specific to arthroscopy in these indications. Meniscal and ligamentous pathologies of the knee, rotator-cuff pathology in the shoulder and tendon pathology in the elbow were not significantly elevated, although a trend emerged. In contrast, there was significant elevation of Achilles and plantar aponeurosis pathology. In terms of postoperative complications, thromboembolic risk was elevated, but there were not significantly more complications specific to arthroscopy. Finally, subjective results were comparable to those for non-obese patients. LEVEL OF EVIDENCE: Review.

Oral information in orthopaedics: how should the patient's understanding be assessed?

INTRODUCTION: Patient information is governed by recommendations of best practices required from any healthcare professional. The aim of this study was to design a tool to measure patient comprehension of the information provided during a surgical consultation before a scheduled surgery. MATERIAL AND METHODS: This was a single-center prospective study of 21 patients using a rating scale-type visual analog scale. Each patient was interviewed and asked to score his or her understanding of the information provided. The investigator checked the external validity of the tool using questions to assess patient's understanding level. RESULTS: The results show that there is a tendency to overvalue some information (reasons for the intervention and alternatives to surgery) and that certain information is not understood (risks and complications) or not provided (postoperative follow-up). CONCLUSION: This study confirms that a rating scale can measure the understanding of information and there is a variation between perceived and actual understanding.

[Evaluation of the theoretical teaching of postgraduate medical students in France]. / Évaluation nationale de l'enseignement théorique du troisième cycle des études médicales en France.

OBJECTIVES: In France, medical students regularly complain about the shortcomings of their theoretical training and the necessity of its adaptation to better fit the needs of students. The goal was to evaluate the theoretical teaching practices in postgraduate medical studies by: 1) collecting data from medical students in different medical faculties in France; 2) comparing this data with expected practices when it is possible; 3) and proposing several lines of improvement. METHODS: A survey of theoretical practices in the 3rd cycle of medical studies was conducted by self-administered questionnaires which were free of charge, anonymous, and administered electronically from July 3 to October 31, 2013 to all medical students in France. RESULTS: National, inter-regional, regional and field internship educational content was absent in respectively 50.5%, 42.8%, 26.0% and 30.2% of cases. Medical students follow complementary training due to insufficient DES and/or DESC 2 training in 43.7% of cases or as part of a professional project in 54.9% of cases. The knowledge sought by medical students concerns the following crosscutting topics: career development (58.9%), practice management (50.7%), medical English (50.4%) and their specialty organization (49.9%). Fifty-four point one percent would like to be evaluated on their theoretical training on an annual basis. CONCLUSION: The results of this first national survey give insights into the theoretical teaching conditions in postgraduate medical education in France and the aspirations of medical students.

A high endrin concentration in a fatal case.

Gas chromatography coupled to mass spectrometry was employed to quantify endrin in biological fluids in a death attributed to endrin overdose. The blood concentration of endrin was 544.9 mg/l. Results are discussed in the light of the existing literature.

[Follow up of total hip prothesis: storage phosphor versus screen-film radiography]. / Confrontation du couple écran-film conventionnel et des plaques au phosphore dans le suivi des prothèses de hanches.

PURPOSE: Digital radiography may lead to interpretation difficulties in patients with hip prosthesis, especially when initial evaluation was performed using screen film radiography. The purpose of this study was to evaluate inter-observer and inter-technique reproducibility comparing digital and screen-film radiography. MATERIAL AND METHODS: Twenty-eight patients with unilateral (n=24) or bilateral (n=4) hip prosthesis (total=32 prostheses) underwent screen-film and digital (storage phosphor) radiography. The bone-cement and metal-cement interfaces were evaluated for the presence of a lucent line in 14 different sectors reclassified into 3 regions. This evaluation was performed by two independent readers. Inter-observer and inter-technique reproducibility were calculated using kappa values. RESULTS: The inter-observer reproducibility was negligible, poor or average with Kappa values ranging from 0.07 to 0.47. The degree of agreement between the two methods was poor, average or good for both observers with Kappa values ranging from 0.10 to 0.66. CONCLUSION: Although inter-technique agreement is not high, it is better than inter-observer agreement. Therefore, storage phosphor technique should not be rejected for total hip prosthesis follow-up, even though previous films were screen-film radiographs.

[MR-arthrography: general principles and applications]. / L'arthro-IRM: principes et applications.

The recent approval by the French Ministry of Health of the use of intra-articular Gadolinium could promote the increasing use of MR-arthrography in France. Although useful in specific pathologies, it should not be overly prescribed and should be considered only if it provides a more accurate diagnosis than other less invasive techniques. The technical aspects and medico-legal implications of MR-arthrography as well as its various indications are reviewed in this article. There are three possible techniques: indirect MR-arthrography with IV Gadolinium injection, direct MR-arthrography with intra-articular Gadolinium injection and lastly, direct MR-arthrography with intra-articular injection of iodinated contrast media (or saline solution). Indirect MR-arthrography cannot be recommended because of insufficient contrast enhancement and the absence of joint filling. Conversely, direct MR-arthrography allows joint expansion which smooths out capsule and ligaments, better delineates articular surfaces and yields a homogeneous high intensity signal of the entire joint. Direct MR-arthrography with iodinated contrast media combines standard arthrography with conventional MRI. Direct MR-arthrography with intra-articular injection of dilute Gadolinium is associated with T1WI, usually of higher quality than T2WI, even though the latter remains part of the protocol. Although, the last two techniques yield higher image quality and are often performed for various articular pathologies, they should not be randomly carried out in the evaluation of joint pathology. However, they should be recommended as the first step in the diagnosis of painful shoulders or hips in young adults and athletes.