Return to Sport and Duty in French Military Personnel after Medial Opening Wedge High Tibial Osteotomy.

INTRODUCTION: Medial opening wedge high tibial osteotomy (MOWHTO) is a surgical option for medial femorotibial osteoarthritis, which preserves articular cartilage by correcting the extra-articular deformities of the lower limbs that cause osteoarthritis. This is an increasingly popular treatment in a population with high functional demand, such as the French military population. The aim of this study was to evaluate the rate of return to work and military activities at 6 months postsurgery and at last follow-up in this military population following MOWHTO.The hypothesis of this study was that MOWHTO enabled a majority of service members to return to the same level of activity within 6 months of surgery. MATERIALS AND METHODS: This was a retrospective, multicenter study including all French military personnel operated on for MOWHTO alone for osteoarthritis of medial compartment between 2008 and 2018 in different Military Teaching Hospitals. We excluded civilian patients. For each patient, a questionnaire was used to collect epidemiological, professional, sports, and functional data. The primary endpoint was the rate of return to work at 6 months postsurgery. We also studied the recovery of sports activities and functional results at a 6.6-year follow-up by standardized questionnaires (Tegner activity scale, Lysholm, IKDC subjective (International Knee Documentation Commitee)). RESULTS: Twenty-four MOWHTOs were performed during this period in a cohort of 22 French military personnel. Return to work at 6 months was possible in 20/24 cases (83.3%). Of the four patients who did not return to work at 6 months, two changed their activities, while the other two returned to their jobs after 6 months. The rate of resumption of sporting activities at an equal or higher level was 50% (11/22). There was no difference between pre- and postoperative Tegner Activity Scale scores at the longest follow-up (P = .08). The mean postoperative Lysholm scores were 73.5 (standard deviation 17.8) and IKDC 59 (standard deviation 8.7). No intraoperative complications were found, and one case of postoperative infection was found. CONCLUSIONS: A total of 83% of the operated soldiers were able to return to their professional activities in less than 6 months. We observed a functional improvement at the last follow-up. Comparing these results with data from civilian populations, the rate of occupational recovery is comparable. However, the return to sport is much better in the series of nonmilitary patients with approximately 90% return to work and sport in the year following surgery. MOWHTO improves the functional results of the knee, enabling a return to work and sport in most cases in young, active populations such as the French military.

Return to military duty following anterior cruciate ligament reconstruction is associated with preoperative Body Mass Index and postoperative physiotherapy.

PURPOSE: To determine the rate and time of return to duty following anterior cruciate ligament reconstruction (ACLR) in military members, and to determine whether their outcomes are influenced by patient characteristics or surgical parameters. METHODS: We prospectively assessed 280 military members that underwent ACLR. 27 were excluded due to multi-ligamentous injuries or revision surgery, two did not provide informed consent and 62 were lost to follow-up. Patient demographics, pre-injury physical workload, complications and whether/when patients resumed duty and sports were noted, as well as clinical outcomes at a minimum follow-up of one year, including Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score (IKDC), Lysholm, and Tegner scale. RESULTS: The final cohort of 189 military members (82% men) had mean age of 25.5 ± 3.4 (range,19-38) at ACLR. At 3.3 ± 1.6 years (range, 1.0-6.3), the Tegner score was 6.1 ± 2.0, Lysholm was 87.0 ± 13.7, IKDC was 80.1 ± 15.7, and KOOS was 81.1 ± 14.8. Only 144 patients (76%) resumed duty, at 9.5 ± 5.3 months (range,1-28), and 141 patients (75%) resumed sport, at 10.2 ± 6.2 months (range,1-35). Multivariable analysis revealed that return to duty was less likely in patients with higher BMI (OR,0.89;p = 0.025), but more likely in patients that followed military physiotherapy (OR,2.76;p = 0.017) and with higher pre-injury physical workload (OR,3.93;p = 0.010). CONCLUSION: At a follow-up of 3.3 ± 1.6 years, 76% returned to duty at 9.5 ± 5.3 months, and 75% returned to their main sport at 10.2 ± 6.2 months. Patients with higher BMI are significantly less likely to resume military duty and sports; those that followed military physiotherapy were most likely to resume duty, while those that had greater pre-injury physical workload were more likely to both resume duty and sport.

Treating osteoarticular infections in a Role 2 in Chad: a bacterial epidemiological study.

INTRODUCTION: The treatment of osteoarticular infections in Africa is a medical and surgical challenge due to the difficulties in managing antibiotic therapy after the surgical procedure. The objectives of this study were to identify the types of bacteria in osteoarticular lesions in patients treated in Chad and to determine the spectrum of resistance encountered and the efficacy of available antibiotics. MATERIAL AND METHODS: This is a retrospective study of all intraoperative osteoarticular and soft tissue samples taken in a French Role 2 Medical Treatment Facility of N'Djamena during surgery for chronic osteoarticular infections, in Chad, for 1 year. RESULTS: A total of 160 bacterial strains were identified, with a predominance of Gram-negative bacillus (GNB) and staphylococcus infections. Among staphylococci, 80% were methicillin-sensitive streptococci which were generally multidrug-sensitive. Enterococci were resistant to third-generation cephalosporins, first-generation fluoroquinolones and gentamycin. Among GNB, there was a predominance of enterobacteria compared with non-fermenting GNB, of which 52% were multidrug-resistant and produced extended spectrum beta-lactamases (ESBL). CONCLUSION: Staphylococcus aureus infections are most often sensitive to available antibiotics and therefore have better prognoses than infections caused by other bacteria. In contrast, in half of the cases of GNB, infections were caused by bacteria producing ESBL, thus posing the problem of multidrug-resistance, the risks of which are increased in precarious situations. Therefore, the type of bacteria appears to be a major prognostic factor in the treatment of osteoarticular infections in a Role 2 in Chad. This criterion will need to be considered before any treatment decisions are made.

Application of the Masquelet technique in austere environments: experience from a French forward surgical unit deployed in Chad.

PURPOSE: We sought to evaluate the results of the Masquelet-induced membrane technique (IMT) for long bone defect reconstruction within the limited-resource setting of a French forward surgical unit deployed in Chad. METHODS: A prospective and observational study was conducted in all patients with a traumatic segmental bone defect in any anatomical location treated by IMT from November 2015 to December 2019. Although IMT was applied by various orthopedic surgeons with variable expertise, all followed the same surgical protocol. Endpoint assessment was performed 12 months after IMT application. RESULTS: Sixteen patients with a mean age of 32.7 years were included in the study. Bone defects were located on the tibia (n = 8), the femur (n = 6) or the radius (n = 2). Thirteen bone defects were infected. After debridement, the mean bone defect length was 4.3 cm. External fixation of the tibia and femur was predominant in both stages. Bone union was achieved in only 8 of the 16 cases at a mean time of 7.6 months. All failures were related to persistent infection or insufficient fixation stability in the second stage. CONCLUSIONS: This series is the first to report IMT use in a forward surgical unit. Despite frequent complications, local patients can benefit from this procedure, which is the only available method for bone reconstruction in areas with limited medical resources. A rigorous technical completion at both stages is crucial to limit septic or mechanical failures.

Prolonged tactical tourniquet application for extremity combat injuries during war against terrorism in the Sahelian strip.

PURPOSE: This study reports on complications following extended tourniquet application in patients with combat extremity injuries treated by the French Military Health Service in the Sahelian strip. METHODS: A retrospective review was performed in a French forward medical treatment facility deployed in Gao, Mali, between 2015 and 2020. All patients treated for an extremity injury with the application of at least one tourniquet for a minimum of 3 h were included. Prehospital data were injury pattern, associated shock, tourniquet location, and duration. Subsequent complications and surgical procedures performed were analyzed. RESULTS: Eleven patients with a mean age of 27.4 years (range 21-35 years) were included. They represented 39% of all patients in whom a tourniquet was applied. They had gunshot wounds (n = 7) or multiple blast injuries (n = 4) and totaled 14 extremity injuries requiring tourniquet application. The median ISS was 13 (interquartile range: 13). Tourniquets were mostly applied proximally on the limb for a mean duration of 268 min (range 180-360 min). Rhabdomyolysis was present in all cases. The damage control surgeries included debridement, external fixation, vascular repair, and primary amputation. Ten injuries were complicated by compartment syndrome requiring leg or thigh fasciotomy in the field or after repatriation. Two severely injured patients died of their wounds, but the others had a favorable outcome even though secondary amputation was sometimes required. CONCLUSIONS: Extended and proximal tourniquet applications led to significant morbidity related to compartment syndrome and rhabdomyolysis. Hemorrhagic shock, mass casualty incident, and tactical constraints often precluded revising the temporary tourniquet applied under fire.

[Dressing management in limb traumatology]. / La gestion des pansements en traumatologie des membres.

The nurse's role in the management of dressings in limb trauma is essential: conditioning of the patient, correct and complete assessment of the site concerned, before care is provided. She is a privileged partner in planning the follow-up. At each stage, the nurse must be aware of the tasks to be carried out so that the overall management leads to rapid and correct healing.

Repeated Induced-Membrane Technique Failure without Infection: A Series of Three Consecutive Procedures Performed for a Single Femur Defect.

A 40-year-old male was treated using the induced-membrane technique (IMT) for a noninfected, 9 cm long femoral bone defect complicating a lengthening procedure. The interesting case feature lies in the three consecutive IMT procedures that were necessary to achieve complete bone repair in this unusual clinical situation. The first procedure failed because of the lack of graft revascularization likely related to an induced-membrane (IM) alteration demonstrated by histological observations. The second IMT procedure led to partial graft integration interrupted by the elongation nail breakage. At last, the third procedure fully succeeded after nail exchange and iterative iliac bone grafting. Complete bone union was achieved with a poor functional recovery one year after the last procedure and four years following the first cement spacer implantation. By means of clinical and histological observations, we demonstrated that the first and the second IMT failures had two distinct origins, namely, biological and mechanical causes, respectively. Although simple, a successful IMT procedure is not so easy to complete.

Induced membrane technique with sequential internal fixation: use of a reinforced spacer for reconstruction of infected bone defects.

PURPOSE: To evaluate a novel sequential internal fixation strategy using a reinforced spacer for infected bone defect reconstruction by the induced membrane technique (IMT). METHODS: A retrospective case study was performed among patients treated for infected bone defects by applying this strategy. Following radical debridement, temporary stabilization was provided by a massive cement spacer combined with minimal intramedullary fixation during step 1. Definitive internal fixation was performed together with bone grafting at step 2. RESULTS: Eight patients with a mean age of 58 years were reviewed. The mean bone defect length was 8.8 cm. The spacer armature mostly consisted of elastic nails and Steinmann pins. Iterative debridement was required in one case after step 1. The mean interval between steps was 12 weeks. Definitive internal fixation was performed by intramedullary nailing (n = 4) or plating (n = 4). At a mean follow-up of 21 months, bone union was achieved in seven cases without additional bone grafting or infection recurrence. CONCLUSIONS: Sequential internal fixation using a reinforced cement spacer seems to be a valuable option for avoiding external fixation between IMT steps and limiting the recurrence of infection.

Towards Understanding Therapeutic Failures in Masquelet Surgery: First Evidence that Defective Induced Membrane Properties are Associated with Clinical Failures.

The two-stage Masquelet induced-membrane technique (IMT) consists of cement spacer-driven membrane induction followed by an autologous cancellous bone implantation in this membrane to promote large bone defect repairs. For the first time, this study aims at correlating IMT failures with physiological alterations of the induced membrane (IM) in patients. For this purpose, we compared various histological, immunohistochemical and gene expression parameters obtained from IM collected in patients categorized lately as successfully (Responders; n = 8) or unsuccessfully (Non-responders; n = 3) treated with the Masquelet technique (6 month clinical and radiologic post-surgery follow-up). While angiogenesis or macrophage distribution pattern remained unmodified in non-responder IM as compared to responder IM, we evidenced an absence of mesenchymal stem cells and reduced density of fibroblast-like cells in non-responder IM. Furthermore, non-responder IM exhibited altered extracellular matrix (ECM) remodeling parameters such as a lower expression ratio of metalloproteinase-9 (MMP-9)/tissue inhibitor of metalloproteinases (TIMP-1) mRNA as well as an important collagen overexpression as shown by picrosirius red staining. In summary, this study is the first to report evidence that IMT failure can be related to defective IM properties while underlining the importance of ECM remodeling parameters, particularly the MMP-9/TIMP-1 gene expression ratio, as early predictive biomarkers of the IMT outcome regardless of the type of bone, fracture or patient characteristics.

[Diagnosing textiloma post-surgery]. / Savoir évoquer le diagnostic de textilome en post-opératoire d'une chirurgie.

During care follow-up, specifically local post-operative care, nurses closely monitor the surgical site both for healing and for local, regional or general risk of infection. In this context, they are on the front line of identifying and reporting any suspicious clinical conditions. We use the example of a patient who presented with textiloma following orthopaedic shoulder surgery.

Use of intramedullary nailing in poor sanitary conditions: French Military Medical Service experience.

INTRODUCTION: Intramedullary (IM) nailing is the gold standard for treating long bone fractures in developed countries because of its minimally-invasive application and good biomechanical properties. In precarious conditions, external fixation or open plate fixation are often performed because surgeons do not have the means to carry out IM nailing. However, these procedures can lead to infection-related complications and mechanical failures. The aim of our study was to describe the outcomes and postoperative complications of IM nailing of closed, long bone fractures in patients operated in a French front-line combat surgical unit (role 2+). Our hypothesis was that IM nailing is a reliable technique with low morbidity for the initial treatment of long bone fractures, even in precarious situations. MATERIAL AND METHODS: This was a prospective, single-center, descriptive study of patients operated on between April 2016 and November 2017. All the patients with a closed femur or tibia fracture who were treated by IM nailing were eligible, no matter their time to surgery. The minimum follow-up was 6 months. The primary endpoint was the absence of infection-related complications and the secondary endpoint was fracture union. RESULTS: Fifty-eight patients were reviewed after an average follow-up of 4.7 months (range, 3-15 months). The mean patient age was 35.2 years (15-85 years) and the majority of patients were men (52 of 58). The fracture was in the femur in 74.1% (n=43) of cases and in the tibia in 25.9% (n=15) of cases. The time to surgery averaged 122.3 days (7-720 days) with a median of 60 days. In 74% of cases (n=43), fracture realignment required an open surgical approach. The postoperative course was considered normal in 96.6% of cases (n=51). No infections were reported as of the last follow-up visit. Union occurred in an average of 4 months in 70.7% of cases (n=41). There were three cases of nonunion after 6 months. DISCUSSION: Even in precarious situations, IM nailing is an effective, reliable method with a low complication risk and high union rate for the treatment of neglected long bone fractures. This surgical treatment is well suited to the poor sanitary conditions on the African continent. LEVEL OF EVIDENCE: II, low-powered prospective study.

Long-Term Results of a Monocentric Series of Soldiers After Latarjet Procedure for Anterior Shoulder Instability. Implications for the Assessment of Soldiers' Medical Ability.

Introduction: Stabilizing surgery of the shoulder with a coracoid graft according to Latarjet is a recognized surgical treatment for anterior instability of the shoulder. This pathology frequently affects soldiers. Postoperatively, the potential risk of recurrence or of secondary shoulder arthritis can limit the practitioner in their ability assessment. The aim of this study is to analyze the long-term outcomes of this surgery in a military population, in order to assess the possible implications for French soldiers' medical ability. Material and Methods: Twenty soldiers operated on the shoulder by Latarjet procedure by the same surgeon were retrospectively reviewed after more than 15 yr. All of them did regular physical activity for leisure or competitions. None had preoperative osteoarthritis injuries. The number of dislocation recurrences, the functional score, and the rate of radiographic osteoarthritis were assessed. Results: After more than 16.3 yr (extremes: 15-24 yr), none displayed a dislocation recurrence. The average Rowe's score was 91.8 ± 9.9. The average subjective shoulder value was 89.2 ± 9.7. All patients had resumed sport. Three of them developed level 1 or 2 radiological signs of osteoarthritis according to Samilson. No level 3 or 4 osteoarthritis was found. Among all the patients, 14 still did regular physical activity. Discussion: In view of our results and of those from the literature, the results of treatment for anterior shoulder instability with the Latarjet procedure are good, even very good in the long term. These data must be considered to favor this procedure for soldiers with shoulder instability and from a medico-administrative viewpoint for military patients in order to pursue their careers without any job restrictions.

Anterior shoulder stabilization by Bristow-Latarjet procedure in athletes: return-to-sport and functional outcomes at minimum 2-year follow-up.

PURPOSE: The aim of this study was to assess return-to-sport outcomes following the Latarjet-Bristow procedure. METHODS: This retrospective study included all athletes <50 years old, who underwent a Latarjet-Bristow procedure for anterior shoulder instability in 2009-2012. Main criteria assessments were the number of athletes returning to any sport and the number returning to the same sport at their preinjury level. The main follow-up was 46.8 ± 9.7 months. RESULTS: Forty-seven patients were analyzed, 46 men/1 women, mean age 27.9 ± 7.9 years. Eighteen patients practiced competitive sports and 29 recreational sports. None of them were professional athletes. One hundred percent returned to sports after a mean 6.3 ± 4.3 months. Thirty/47 (63.8 %) patients returned to the same sport at the same level at least and 10/47 (21.3 %) patients changed sport because of their shoulder. Compared to patients who returned to the same sport at the same level, patients who changed sports or returned to a lower level had practiced overhead or forced overhead sports [OR = 4.7 (1.3-16.9), p = 0.02] before surgery, experienced avoidance behavior at the final follow-up (p = 0.002), apprehension (p = 0.00001) and had a worse Western Ontario Shoulder Instability Index score and sub-items (p = 0.003) except for daily activities (p = 0.21). At the final follow-up, 45/47 (95.7 %) patients were still practicing a sport. CONCLUSION: All the patients returned to sports, most to their preinjury sport at the same level. Patients who practiced an overhead sport were more likely to play at a lower level or to change sport postoperatively. LEVEL OF EVIDENCE: IV, retrospective study-Case series with no comparison group.