Biomechanical study of dynamic changes in L4-L5 foramen surface area in flexion and extension after implantation of four interspinous process devices.

BACKGROUND: Lumbar spinal stenosis is a major public health issue. Interspinous devices implanted using minimally invasive techniques may constitute an alternative to the reference standard of bony decompression with or without intervertebral fusion. However, their indications remain unclear, due to a paucity of clinical and biomechanical data. Our objective was to evaluate the effects of four interspinous process devices implanted at L4-L5 on the intervertebral foramen surface areas at the treated and adjacent levels, in flexion and in extension. MATERIALS AND METHOD: Six fresh frozen human cadaver lumbar spines (L2-sacrum) were tested on a dedicated spinal loading frame, in flexion and extension, from 0 to 10 N·m, after preparation and marking of the L3-L4, L4-L5, and L5-S1 foramina. Stereoscopic 3D images were acquired at baseline then after implantation at L4-L5 of each of the four devices (Inspace(®), Synthes; X-Stop(®), Medtronic; Wallis(®), Zimmer; and Diam(®), Medtronic). The surface areas of the three foramina of interest were computed. RESULTS: All four devices significantly opened the L4-L5 foramen in extension. The effects in flexion separated the devices into two categories. With the two devices characterized by fixation in the spinous processes (Wallis(®) and Diam(®)), the L4-L5 foramen opened only in extension; whereas with the other two devices (X-Stop(®) and Inspace(®)), the L4-L5 foramen opened not only in extension, but also in flexion and in the neutral position. None of the devices implanted at L4-L5 modified the size of the L3-L4 foramen. X-Stop(®) and Diam(®) closed the L5-S1 foramen in extension, whereas the other two devices had no effect at this level. CONCLUSION: Our results demonstrate that interspinous process devices modify the surface area of the interspinous foramina in vitro. Clinical studies are needed to clarify patient selection criteria for interspinous process device implantation. LEVEL OF EVIDENCE: Level IV. Investigating an orthopaedic device.

Tuberoplasty: minimally invasive osteosynthesis technique for tibial plateau fractures.

Fractures of the tibial plateau are in constant progression. They affect an elderly population suffering from a number of comorbidities, but also a young population increasingly practicing high-risk sports and using two-wheeled vehicles. The objective of this study was therefore to propose a new technique for the treatment of this type of fracture. There are a variety of classical pitfalls of conservative treatment such as defective reduction resulting in early osteoarthritis and alignment defects. Conventional treatments lead to joint stiffness and amyotrophy of the quadriceps, caused by the open technique and late loading. We propose an osteosynthesis technique for tibial plateau fractures with minimally invasive surgery. A minimally invasive technique would be more appropriate to remedy all of the surgical drawbacks resulting from current practices. The surgical technique that we propose uses a balloon allowing progressive and total reduction, associated with percutaneous screw fixation and filling with polymethylmethacrylate (PMMA) cement. The advantages are optimal reduction, minimal devascularization, soft tissues kept intact, as well as early loading and mobilization. This simple technique seems to be a good alternative to conventional treatment. The most comminuted fractures as well as the most posterior compressions can be treated, while causing the least impairment possible. Arthroscopy can be used to verify fracture reduction and cement leakage. At the same time, it can be used to assess the associated meniscal lesions and to repair them if necessary.

Abnormalities of the gallbladder, clinical effects.

The aim of this review of the literature was to present and discuss the anatomical and embryological basis of congenital abnormalities of the gallbladder, based on a case of volvulus. In the rare cases of ectopic gallbladder, diagnosis of a biliary disease could be difficult. In such cases surgery can also be dangerous, especially when it is associated with abnormalities of the intra-hepatic biliary and vascular tree. This study, based on the embryology of the extra hepatic bile duct, focused on the most frequent gallbladder abnormalities to keep them in mind.

Anatomical pitfalls in the technique for total extra peritoneal laparoscopic repair for inguinal hernias.

PURPOSE: The totally extraperitoneal laparoscopic approach for the treatment of inguinal hernia is a well-recognized technique with proven efficacy, low failure rate, and reduced post-operative pain. This laparoscopic technique is reputed to be a more difficult procedure to learn and practice than a laparoscopic trans-abdomino-pre-peritoneal procedure: we hope this is because many surgeons don't well know extra-peritoneal anatomy of groin. So we proposed a "step by step" anatomical analysis, with pitfalls to avoid, of a totally extraperitoneal laparoscopic approach for treatment of inguinal hernia. METHODS: Our experience with totally extraperitoneal laparoscopic inguinal hernia repair with regard to the morphology of the inguinal-femoral region concerns 23 cadaver dissection and more than 400 surgical procedures, now permits clarification of a surgical technique that has hitherto not been well known. CONCLUSION: Photographic representations of surgical views are displayed, and detailed descriptions applicable to anatomical structures are presented.

[A new method for radio-carpal joint injection]. / Une nouvelle technique de ponction de l'articulation radio-carpienne.

OBJECTIVE: Previous techniques for radiocarpal joint injection introduce the needle directly between the navicular and the radius. We propose here a new technique using the same puncture site for midcarpal and radiocarpal arthrograms without need for needle reinsertion. MATERIALS AND METHODS: A prospective study of 85 radiocarpal injections for arthrography was performed. For each case, the needle tip was positioned at the medial part of the proximal scaphoid, under the mid carpal joint, and directed obliquely with a 45 degrees angle to the joint space to reach the radiocarpal joint. In case of midcarpal and radiocarpal arthrograms, a single puncture site was always used. RESULTS: Injection of the radiocarpal joint was successful in 82 of the 82 cases. CONCLUSION: The method proposed here is simple, efficient and uses a single site of puncture in cases requiring bi-compartmental injections.

The pectineal ligament: anatomical study and surgical applications.

The aim of this study was to reinforce the importance of the pectineal ligament in laparoscopic surgery for groin hernia and female urinary incontinence, particularly its anatomical importance in the myopectineal region. A morphologic study was conducted on 44 pectineal ligaments from 23 embalmed and one fresh human cadavers, together with a radiological study on four volunteer patients. Anatomical and histological findings confirm the fact that the ligament of Cooper represents a thickening of the pectineal fascia rather than a thickening from the periosteum. The pectineal ligament provides a landmark in each approach, open or laparoscopic, anterior or posterior surgery.

[Krukenberg's tumor. Apropos of a case. Review of the literature]. / Tumeur de Krukenberg. A propos d'un cas. Revue de la littérature.

A case is reported of krükenberg's tumor, this rare lesion characterized by the constant presence of typical signet ring cells being an ovarian metastasis from a general digestive cancer. The primary neoplasm is often overlooked while the ovarian tumor is already large and bilateral. In a pregnant patient with this lesion virilization of mother and child may occur, this endocrine activity being poorly documented and the subject of a literature review. The pathogenicity of this tumor is still unknown. Endocrine investigations should be enlarged in the fairly rare cases when diagnosis is suspected prior to ovarian excision. Treatment is currently surgical but survival is little improved. Other therapy is only poorly effective.