Atypical influence of biomechanical knowledge in Complex Regional Pain Syndrome-towards a different perspective on body representation.

Part of the multifaceted pathophysiology of Complex Regional Pain Syndrome (CRPS) is ascribed to lateralized maladaptive neuroplasticity in sensorimotor cortices, corroborated by behavioral studies indicating that patients present difficulties in mentally representing their painful limb. Such difficulties are widely measured with hand laterality judgment tasks (HLT), which are also used in the rehabilitation of CRPS to activate motor imagery and restore the cortical representation of the painful limb. The potential of these tasks to elicit motor imagery is critical to their use in therapy, yet, the influence of the body's biomechanical constraints (BMC) on HLT reaction time, supposed to index motor imagery activation, is rarely verified. Here we investigated the influence of BMC on the perception of hand postures and movements in upper-limb CRPS. Patients were slower than controls in judging hand laterality, whether or not stimuli corresponded to their painful hand. Reaction time patterns reflecting BMC were mostly absent in CRPS and controls. A second experiment therefore directly investigated the influence of implicit knowledge of BMC on hand movement judgments. Participants judged the perceived path of movement between two depicted hand positions, with only one of two proposed paths that was biomechanically plausible. While the controls mostly chose the biomechanically plausible path, patients did not. These findings show non-lateralized body representation impairments in CRPS, possibly related to difficulties in using correct knowledge of the body's biomechanics. Importantly, they demonstrate the challenge of reliably measuring motor imagery with the HLT, which has important implications for the rehabilitation with these tasks.

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.

Higher preoperative range of motion is predictive of good mid-term results in the surgical management of osteochondral lesions of the talus: a prospective multicentric study.

INTRODUCTION: Osteochondral lesions of the talus (OLT) are a frequent cause of pain in young patients and a new CT arthrographic classification system of OLT was recently proposed to help guide the choices of and standardize the indications for surgical treatment. The primary hypothesis was that this algorithm would result in a postoperative AOFAS score of ≥ 80/100. The secondary hypothesis was to identify the preoperative factors of successful surgery. METHODS: This was a prospective observational multicenter study. Eighty-six patients who underwent surgery for OLT after at least 6 months of unsuccessful conservative management were included for a mean follow-up of 15 months (12-36). Forty-nine patients with stage 1 OLT underwent microperforation, 2 patients with stage 2 OLT underwent a lift, drill, fill, and fix graft procedure with screw fixation, and 35 patients with stage 3 OLT were treated with mosaicplasty. RESULTS: After a follow-up of at least 1 year, 56 patients (65%) had an AOFAS score > 80 and the mean AOFAS score was 82 (16-100). A lower BMI (p = 0.038), a higher preoperative range of motion in the ankle (p = 0.033), higher preoperative AOFAS and FAOS scores (p = 0.001 and p = 0.011), and the presence of a preoperative bone bruise on MRI (p = 0.020) were good prognostic factors on univariate analysis. The presence of grade 1 osteoarthritis on the Van Dijk classification was predictive of a poor prognosis (p = 0.044). Multivariate analysis showed that a good preoperative range of motion (OR = 1.080 [1.020-1.150] p = 0.01) was predictive of a positive outcome, while grade 1 osteoarthritis was predictive of a poor outcome (OR = 0.147 [0.036-0.603] p = 0.008). The postoperative AOFAS decreased in six patients and 17 patients had at least one complication: six dysthesias of the superficial fibular nerve, two of the sural nerve, and nine stage 1 complex regional pain syndromes. CONCLUSION: The new algorithm for OLT resulted in a postoperative AOFAS score of ≥ 80/100 in 65% of cases. The positive predictive factors of a successful postoperative outcome were the presence of a good preoperative range of motion and the absence of preoperative osteoarthritis. LEVEL OF EVIDENCE: Level II.

Effect of splint on pain, function and quality of life in trapeziometacarpal osteoarthritis patients?

Trapeziometacarpal (TM) Osteoarthritis is one of the most common osteoarthritis. It causes pain, loss of mobility and strength and affected function in daily life. Splint is one of the conservative treatments proposed to patients. The purpose of this study was to assess the effect of this conservative treatment on pain, function and quality of life at long-term. We sent 193 questionnaires to patients who received a CMC splint for their TM osteoarthritis. The CMC splint immobilizes only the TM joint and leaves free the interphalangeal joint of the thumb and the wrist. First, we comptuted how many patients had finally undergone surgical treatment. On the non-operated patients, we analyzed the pain (VAS), the function (QuickDASH score) and the quality of life (SF-12). We compared the results to literature and norms. Finally, 186 people could be included in the study ,115 we answered and 28 were operated on (24%). After 4 years (3.8±1.7 yrs) of conservative treatment, The VAS and QuickDASH scores were significantly worse comparatively to a cohort of healthy patients, trapezectomy and arthrodesis patients. The SF-12 scores were reduced from 20% comparative to norms. In conclusion, few patients had surgery after splinting as a conservative treatment. However, these non- operated patients do not provide good results.

Evaluation of a fellowship abroad as part of the initial training of the French military surgeon.

INTRODUCTION: Military surgery requires skills that in general cannot be easily learnt in civilian training. Participation in a fellowship abroad adapted to the particular operating conditions of the foreign deployment is one route that might secure the necessary supplementary training. We therefore assessed the relevance of such a fellowship in the preparedness of young military surgeons in their first deployment. METHODS: This study included all active military surgeons who had completed a fellowship abroad during their initial training from 2004 to 2017 in Tchad or Senegal or Djibouti. The collection of data was performed using a questionnaire. The main judgement criterion was the rate of positive answers awarded to the relevance of this fellowship in the preparedness of respondents' first foreign deployment. RESULTS: Sixty-nine of 73 surgeons answered. Sixty-one estimated the fellowship had allowed them to feel more operational during their first mission, with 83.61% rating this feeling as important. Also, 61 recommended the use of a fellowship for war surgery training. The grade assigned to the surgical benefit was 8.48/10. CONCLUSION: A fellowship abroad permits one to become familiar with surgical practice under austere circumstances and the particularities of the surgical structures at the front. Current trainees' feedback confirms its relevance.

Effect of cadmium on the viability on monolayer cultures of synoviocytes, chondrocytes, and Hoffa: A preliminary study.

Osteoarthritis (OA) is the gradual loss of articular cartilage and involves several tissues, such as the synovial membrane, meniscus, ligaments, and adipose tissue known as Hoffa fat pad. There are largely unexplored factors that lead to OA development, such as the impact of exposure to heavy metals like cadmium (Cd) on the viability of cells in the knee joint tissue. The objective of this report was to identify the cell type with the highest susceptibility to Cd toxicity with respect to cell viability and death. Our findings showed that a concentration as low as 3 µM cadmium chloride for 12 h affects the viability of synovial cells, and a concentration of 10 µM affects Hoffa cells. Our results suggest that Cd can affect the viability of synovial and chondral cells primarily. In contrast, Hoffa cells were less susceptible, likely because Cd favors the production of pro-inflammatory cytokines before triggering their death as part of its damage mechanism at the articular level.

S-adenosyl-L-methionine (SAMe) halts the autoimmune response in patients with primary biliary cholangitis (PBC) via antioxidant and S-glutathionylation processes in cholangiocytes.

S-adenosyl-L-methionine is an endogenous molecule with hepato-protective properties linked to redox regulation and methylation. Here, the potential therapeutic value of SAMe was tested in 17 patients with PBC, a cholestatic disease with autoimmune phenomena targeting small bile ducts. Nine patients responded to SAMe (SAMe responders) with increased serum protein S-glutathionylation. That posttranslational protein modification was associated with reduction of serum anti-mitochondrial autoantibodies (AMA-M2) titers and improvement of liver biochemistry. Clinically, SAMe responders were younger at diagnosis, had longer duration of the disease and lower level of serum S-glutathionylated proteins at entry. SAMe treatment was associated with negative correlation between protein S-glutathionylation and TNFα. Furthermore, AMA-M2 titers correlated positively with INFγ and FGF-19 while negatively with TGFß. Additionally, cirrhotic PBC livers showed reduced levels of glutathionylated proteins, glutaredoxine-1 (Grx-1) and GSH synthase (GS). The effect of SAMe was also analyzed in vitro. In human cholangiocytes overexpressing miR-506, which induces PBC-like features, SAMe increased total protein S-glutathionylation and the level of γ-glutamylcysteine ligase (GCLC), whereas reduced Grx-1 level. Moreover, SAMe protected primary human cholangiocytes against mitochondrial oxidative stress induced by tBHQ (tert-Butylhydroquinone) via raising the level of Nrf2 and HO-1. Finally, SAMe reduced apoptosis (cleaved-caspase3) and PDC-E2 (antigen responsible of the AMA-M2) induced experimentally by glycochenodeoxycholic acid (GCDC). These data suggest that SAMe may inhibit autoimmune events in patients with PBC via its antioxidant and S-glutathionylation properties. These findings provide new insights into the molecular events promoting progression of PBC and suggest potential therapeutic application of SAMe in PBC.

Effect of cadmium on the concentration of essential metals in a human chondrocyte micromass culture.

BACKGROUND: An essential element imbalance in the joint might favor gradual degeneration of the articular cartilage. It has been reported that cadmium (Cd) plays an antagonistic role with regards to the presence of essential elements, such as zinc (Zn), iron (Fe), and manganese (Mn), which may favor the development of disabling diseases, like osteoarthritis (OA) and osteoporosis. METHODS: 3D cultures of human chondrocytes were phenotyped with the Western blot technique and structurally evaluated with histological staining. The samples were exposed to 1, 5, and 10 µM of CdCl2 for 12 h, with a non-exposed culture as control. The concentration of Cd, Fe, Mn, Zn, chromium (Cr), and nickel (Ni) was quantified through plasma mass spectrometry (ICP-MS). The data were analyzed with a Kruskal Wallis test, a Kendall's Tau test and Spearman's correlation coefficient with the Stata program, version 14. RESULTS: Our results suggest that Cd exposure affects the structure of micromass cultures and plays an antagonistic role on the concentration of essential metals, such as Zn, Ni, Fe, Mn, and Cr. CONCLUSION: Cd exposure may be a risk factor for developing joint diseases like OA, as it can interfere with cartilage absorption of other essential elements that maintain cartilage homeostasis.

Trapeziometacarpal total joint replacement as an alternative to trapeziectomy depends on trapezium height: Retrospective study of 67 patients.

Surgical indications for trapeziometacarpal (TMC) total joint replacement for thumb basal joint osteoarthritis (OA) are increasing. However, complications following this procedure are not insignificant. To avoid complications, preoperative planning with measurement of trapezium height is indicated to ensure a cup is not implanted in the trapezium if its height is less than 8 millimeters. The objective of our study was to analyze a series of preoperative radiographs of patients managed by trapeziectomy and suspensionplasty in our department, and to assess the possibility of a surgical alternative-total joint replacement-based on the trapezium's height. We also wanted to determine whether radiological height was influenced by the radiological progression of the thumb OA. A single-center retrospective study based on available medical records was conducted. The patients included had TMC OA refractory to conservative treatment and were managed surgically by trapeziectomy and suspensionplasty between 2012 and 2018. Sixty-seven patients were eligible. Based on the Eaton-Littler classification of radiological TMC OA, our case series had 0% (n=0) stage I, 36% (n=24) stage II, 42% (n=28) stage III and 22% (n=15) stage IV findings. We measured the radiological trapezium height on AP and lateral views as described by Kapandji. These were 10.6mm and 10.8mm for stage II, 9.6mm and 8.9mm for stage III, 8.6mm and 7.8mm for stage IV, respectively. Eighty-six percent of patients had a trapezium height suitable for total joint replacement. The radiological height decreased significantly with the OA stage. At stage IV, the average height fell below the 8-mm threshold, compromising the surgical indication for total arthroplasty.

[Thromboembolic risk in repatriated patients with traumatic lower-limb injuries]. / Risque thromboembolique chez les patients traumatisés des membres inférieurs rapatriés.

INTRODUCTION: Venous thromboembolism (VTE) is a public health problem. Medical repatriation of patients with traumatic lower-limb injuries is common. There are no specific recommendations for the prevention of deep vein thrombosis (DVT). The main objective was to determine the incidence of VTE in this high-risk population and to determine associated risk factors. MATERIALS AND METHODS: This was a prospective study including patients repatriated to France following lower-limb trauma and hospital discharge. A physical examination and a venous ultrasound were systematically performed on arrival. Reasons for repatriation, methods of VTE prevention and risk factors for VTE were studied. The positive diagnosis of deep venous thrombosis (DVT) was done by Doppler ultrasound. RESULTS: Fifty-two patients with lower-limb trauma were included. Six cases of DVT, four asymptomatic and two symptomatic with pulmonary embolisms were diagnosed. Two patients with asymptomatic DVT did not have preventive anticoagulation. No patient with preventive anticoagulation had symptomatic DVT. Smoking and the absence of preventive anticoagulation were significant risk factors for VTE. DISCUSSION: Repatriation of patients with lower-limb trauma in discharge is associated with an increased risk of VTE. Preventive anticoagulation appears to be effective in preventing DVT. Systematic Doppler imaging can reveal asymptomatic DVT. Our study did not evaluate specifically the interest of venous compression associated to preventive anticoagulation for VTE prevention. Specific recommendations on VTE prevention during repatriation of patients with lower-limb trauma are needed. CONCLUSION: Preventive anticoagulation should be systematically discussed during repatriation of patients with lower-limb trauma, in the absence of major bleeding risk. Due to the existence of asymptomatic DVT, venous Doppler ultrasound should also be systematically discussed despite the absence of official recommendations.

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.

"Snapping triceps": A rare and misleading condition - a clinical case report.

Snapping triceps corresponds to subluxation of the medial head of the triceps brachii over the medial epicondyle during active elbow flexion. It is a rare and misleading condition that is often associated with ulnar nerve instability. The latter can result in the snapping triceps being missed. Diagnosis requires a detailed clinical examination. Surgical treatment consists of anterior translocation of the nerve with an adipose flap to stabilize it and transfer of the distal attachment of the medial head of triceps brachii.

Damage control: Concept and implementation.

The concept of damage control (DC) is based on a sequential therapeutic strategy that favors physiological restoration over anatomical repair in patients presenting acutely with hemorrhagic trauma. Initially described as damage control surgery (DCS) for war-wounded patients with abdominal penetrating hemorrhagic trauma, this concept is articulated in three steps: surgical control of lesions (hemostasis, sealing of intestinal spillage), physiological restoration, then surgery for definitive repair. This concept was quickly adapted for intensive care management under the name damage control resuscitation (DCR), which refers to the modalities of hospital resuscitation carried out in patients suffering from traumatic hemorrhagic shock within the context of DCS. It is based mainly on specific hemodynamic resuscitation targets associated with early and aggressive hemostasis aimed at prevention or correction of the lethal triad of hypothermia, acidosis and coagulation disorders. Concomitant integration of resuscitation and surgery from the moment of admission has led to the concept of an integrated DCR-DCS approach, which enables initiation of hemostatic resuscitation upon arrival of the injured person, improving the patient's physiological status during surgery without delaying surgery. This concept of DC is constantly evolving; it stresses management of the injured person as early as possible, in order to initiate hemorrhage control and hemostatic resuscitation as soon as possible, evolving into a concept of remote DCR (RDCR), and also extended to diagnostic and therapeutic radiological management under the name of radiological DC (DCRad). DCS is applied only to the most seriously traumatized patients, or in situations of massive influx of injured persons, as its universal application could lead to a significant and unnecessary excess-morbidity to injured patients who could and should undergo definitive treatment from the outset. DCS, when correctly applied, significantly improves the survival rate of war-wounded.

Subacromial temperature profile during bipolar radiofrequency use in shoulder arthroscopy. Comparison of Coblation® vs. VAPR®.

BACKGROUND: The use of bipolar electrodes for arthroscopic procedures carries a theoretical ex vivo risk of inducing burn injuries. Few studies have measured the in vivo temperatures produced by bipolar electrodes during arthroscopy, and their results are conflicting. The objective of this study was to evaluate the temperature profile within the subacromial space during shoulder arthroscopy with two different electrode systems. HYPOTHESIS: The primary hypothesis was that the two electrode systems produced similar temperature variations and peak temperatures. The secondary hypothesis was that neither electrode system produced irrigation-fluid temperatures above the tissue-damage threshold. MATERIAL AND METHODS: A comparative, prospective, single-centre, single-surgeon, single-blind study was conducted to compare the Coblation® system (Smith&Nephew, Andover, MA, USA) and the VAPR® system (DePuy Synthes Mitek Sports Medicine, Raynham, MA, USA) in 13 patients undergoing shoulder arthroscopy. A temperature probe inserted into the subacromial space was used to record temperatures at 10-second intervals for 60seconds during continuous radiofrequency application. RESULTS: Mean baseline temperature was 21.4±0.7°C with VAPR® and 23.0±2.2°C with Coblation®. No significant between-group differences were found during the first 40seconds. The mean peak temperature reached after 60seconds was 25.0±1.9°C with VAPR® and 27.9±2.8°C with Coblation® (P<0.05). DISCUSSION: Few studies have compared the in vivo temperatures produced during arthroscopy by different electrode systems. In vivo studies have established that temperature increases can cause tissue damage, particularly to chondrocytes, and that the irrigation flow rate plays a key role in lowering the in vivo temperatures. Our study showed a significant difference between the two electrode systems after 50seconds of use, with lower temperatures with the VAPR®. Nevertheless, neither system increased the irrigation-fluid temperatures above the tissue-damage threshold. Both systems can be used safely, provided the manufacturer instructions are followed and the irrigation system is effective. LEVEL OF EVIDENCE: II (prospective randomized trial).

Effect of different concentrations of omega-3 fatty acids on stimulated THP-1 macrophages.

BACKGROUND: Inflammation plays a central role in chronic diseases occurring in the contemporary society. The health benefits of omega-3 (n-3) fatty acids (FAs), mostly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have been reported. However, their mechanisms of action are poorly understood. We explored dose and time effects of EPA, DHA, and a mixture of EPA + DHA on the expression of inflammatory genes in stimulated macrophages. METHODS: Lipopolysaccharide was used to stimulate human THP-1 macrophages. Cells were incubated in different conditions in the presence of n-3 FAs and LPS, and mRNA levels of inflammatory genes were measured by real-time PCR. Cytokine levels in culture media were measured. RESULTS: The mixture of EPA + DHA had a more effective inhibitory effect than either DHA or EPA alone, DHA being more potent than EPA. For both EPA and DHA, 75 µM of FAs had a more important anti-inflammatory effect than 10 or 50 µM. For gene expression, EPA had the greater action during the post-incubation (after LPS treatment) condition while DHA and EPA + DHA were more potent during the co-incubation (n-3 FAs and LPS). Cytokine concentrations decreased more markedly in the co-incubation condition. CONCLUSIONS: These results suggest that in stimulated macrophages, expression levels of genes involved in inflammation are influenced by the dose, the type of n-3 FAs, and the time of incubation.

Accuracy and reproducibility of preoperative three-dimensional planning for total hip arthroplasty using biplanar low-dose radiographs : A pilot study.

BACKGROUND: In total hip arthroplasty (THA), the acetabular cup and femoral stem must be correctly sized and positioned to avoid intraoperative and postoperative complications, achieve good functional outcomes and ensure long-term survival. Current two-dimensional (2D) techniques do not provide sufficient accuracy, while low-dose biplanar X-rays (EOS) had not been assessed in this indication. Therefore, we performed a case-control study to : (1) evaluate the prediction of stem and cup size for a new 3D planning technique (stereoradiographic imaging plus 3D modeling) in comparison to 2D templating on film radiographs and (2) evaluate the accuracy and reproducibility of this 3D technique for preoperative THA planning. HYPOTHESIS: Accuracy and reproducibility are better with the 3D vs. 2D method. PATIENTS AND METHODS: Stem and cup sizes were retrospectively determined by two senior surgeons, twice, for a total of 31 unilateral primary THA patients in this pilot study, using 3D preplanning software on low-dose biplanar X-rays and with 2D templating on conventional anteroposterior (AP) film radiographs. Patients with a modular neck or dual-mobility prosthesis were excluded. All patients but one had primary osteoarthritis; one following trauma did not have a cup implanted. The retrospectively planned sizes were compared to the sizes selected during surgery, and intraclass coefficients (ICC) calculated. RESULTS: 3D planning predicted stem size more accurately than 2D templating: stem sizes were planned within one size in 26/31 (84%) of cases in 3D versus 21/31 (68%) in 2D (P=0.04). 3D and 2D planning accuracies were not significantly different for cup size: cup sizes were planned within one size in 28/30 (92%) of cases in 3D versus 26/30 (87%) in 2D (P=0.30). ICC for stem size were 0.88 vs. 0.91 for 3D and 2D, respectively. Inter-operator ICCs for cup size were 0.84 vs. 0.71, respectively. Repetitions of the 3D planning were within one size (except one stem), with the majority predicting the same size. DISCUSSION: Increased accuracy in 3D may be due to the use of actual size (non-magnified) images, and judging fit on AP and lateral images simultaneously. Results for other implant components may differ from those presented. Size selection may improve further with planning experience, based on a feedback loop between planning and surgical execution. LEVEL OF EVIDENCE: Level III. Retrospective case-control study.