Osteosynthesis of periprosthetic type A and B femoral fractures using an unlocked plate with integrated cerclage cable and trochanteric hook: A multicenter retrospective study of 45 patients with mean follow-up of 20 months.

INTRODUCTION: Femoral periprosthetic fracture (FPF) is a frequent complication in dependent elderly persons, with a limited life expectancy. Their management is difficult and the choice between osteosynthesis and prosthesis is still matter of discussion. To date, there is no study on unlocked plate with integrated cerclage cable and trochanteric hook for this indication. The objectives of this study were to analyze fracture healing, complication rate and functional outcome. Our hypothesis is that this technique allows a high rate of consolidation and a return to the previous state in terms of autonomy and place of residence. MATERIALS AND METHODS: We conducted a retrospective multicenter study between 2010 and 2015. The inclusion criteria were: patients with type A and B FPF according to the classification of Vancouver who received osteosynthesis hook plate. The evaluation focused on the consolidation period, complications and pre and postoperative Parker and Katz scores. Death, nonunion, dislocation, infection and failure of fixation were considered major complications. RESULTS: Forty-five patients met the inclusion criteria and were evaluated at mean 20 months (6-72). All fractures consolidated at a mean 7 weeks (6-10), except one that has not undergone further surgery in the absence of functional impairment. Parker score decreased from 6.4 to 4.9 (p=0.03) and Katz score from 4.8 to 4.3 (p=0.045). Five patients died within the year of the operation. Five patients living at home preoperatively were admitted to an institution, the others returned to their retirement home or nursing home. CONCLUSION: This plate allows for a quick and effective management of patients with FPF. The low rate of complications and the very good consolidation rate lead us to use the same plate even for class B2 or B3 fractures in some patients with precarious health condition who cannot tolerate major revision surgery: Elderly, ASA score >3, loss of autonomy, Katz score <4.

Is amputation a viable treatment option in lower extremity trauma?

INTRODUCTION: There is currently no consensus on how to treat patients with lower extremity trauma. Should amputation be performed early on to avoid complications or should the limb be saved at any price? The goal of this study was to show that early amputation is a viable treatment option in lower extremity trauma cases. MATERIAL AND METHODS: Twenty patients who underwent early amputation and 16 patients who underwent limb-salvage were included with a minimum follow-up of 1year. The main endpoints were the Mangled Extremity Severity Score (MESS) used to predict amputation, complications, sequelae, bone union and functional outcomes. RESULTS: The amputees had a higher MESS score than those treated conservatively (7.8 vs. 4.9, P<0.00001), had a shorter hospital stay (P<0.022) and had fewer postoperative complications (P<0.003), especially infection-related (P<0.001). The prevalence of infection in limb-salvage patients was 61%. There was no significant difference between the two groups in terms of quality of life. DISCUSSION: In cases of lower extremity trauma, early amputation and limb-sparing treatment each have their advantages and disadvantages. Early amputation seems to be better in cases of complications, despite similar quality of life in the two groups in the long-term. It is a viable treatment option in cases of lower extremity trauma. Amputation must not be considered as a failure, but a deliberate choice due to the functional impact of complications that occur after limb-salvage. LEVEL OF EVIDENCE: Level IV study.

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.

[Obesity and primiparity: Risky delivery?]. / Obésité et primiparité: accouchement à risque ?

OBJECTIVES: To evaluate the risk of materno-foetal complications in obese primiparous women (Body Mass Index (BMI)≥30) MATERIALS AND METHODS: A retrospective study was conducted in our tertiary referral labour ward from 1st January 2009 to 31st December 2010, including primiparous women delivering living cephalic singleton pregnancies after 37 weeks of amenorrhea. Two groups were compared: obese patients (BMI≥30) and non-obese (BMI<30). Obstetrical and neonatal data were collected. RESULTS: Among 1636 primiparous women, 132 (8%) had a BMI≥30. Induction of labor, prolonged pregnancy and post-partum hemorrhage were significatively more frequent in obese group (P<0.001). Those patients have an increased risk of cesarean section (P<0.001). Mean birth weight of newborns from obese mothers is significatively higher (3493g vs 3265g, P<0.001), as is the frequency of macrosomia (16.7% vs 5.2%, P<0.001). CONCLUSION: Obesity is associated with obstetrical complications in primiparous obese women, who are to be considered risky patients at their arrival in the labour ward, and specific obstetrical management must be planned to improve maternal and neonatal outcomes.

[Active management of the second twin for vaginal delivery: ruptured versus intact membranes. Apropos a series of 182 patients]. / Accouchement manœuvrier du deuxième jumeau: membranes rompues versus membranes intactes. À propos d'une série de 182 patientes.

AIM: The vaginal management of the second twin (T2) differs throughout our country. In 2009, the French National College of Gynecologists and Obstetricians released practice guidelines, with low-level evidence, encouraging active management of the second twin, using maneuvers with intact membrane. PATIENTS AND METHODS: In our level III labour ward, these maneuvers are systematically performed when the second twin is in a breech or transverse presentation and after ruptured membranes in most cases. We studied 182 twin pregnancies with active management of the T2 at more than 28 weeks of gestation, from 1st January 1996 to 31st December 2010, by comparing the membrane status during delivery of T2. RESULTS: The results did not show any significant differences between the two groups of patients concerning the neonatal or maternal results. The technique is feasible, even by residents. Our results show that total breech extraction of the second twin with ruptured membranes is feasible, which allows for reappraisal of the national recommendations. CONCLUSION: In our practice, it is possible to actively deliver the T2 with ruptured membranes without altering maternal and fetal prognosis and thus simplifying learning for young doctors.

[Breech delivery and scarred uterus: a special obstetrical situation?]. / Accouchement du siège et utérus cicatriciel : une situation obstétricale particulière ?

AIM: The management of breech delivery in patients with a history of caesarean section is a special situation requiring to anticipate the delivery route if the usual prerequisites for the acceptance of vaginal breech delivery are present. Does a history of caesarean section imply a systematic refusal of vaginal delivery in case of breech presentation or an alternative to an iterative caesarean still exists? MATERIALS AND METHODS: An observational study was undertaken in our level III labour ward from January 1st 1994 to June 30th 2010 on 91 patients with a history of caesarean section and who had breech deliveries of singleton pregnancies at more than 35weeks of amenorrhea. Maternal, obstetrical and neonatal parameters were collected. Patients were divided into three groups: vaginal delivery, caesarean section after an accepted vaginal birth trial, elective caesarean section. RESULTS: The rate of an accepted vaginal birth trial was 24.2% (22 cases) with a 36.4% (eight patients) success rate in this group. There were two (2.9%) unplanned vaginal births. Fourteen patients (15.4%) had caesarian sections after an accepted vaginal birth trial: ten before labour and four during labour for dynamic dystocia or non-reassuring fetal status. Most caesarean sections before labour in case of an accepted vaginal birth trial were justified by an intercurrent factor requiring induction of labour. Neonatal factors did not show any increased morbidity or mortality in the vaginal birth group. No Apgar score was found to be less than or equal to 7 at 5minutes. Umbilical arterial pH and lactate measured as from 2001 were similar between the groups. Indeed, the mean arterial pH after vaginal birth was 7.19 as compared to 7.22 in case of caesarean section after an accepted vaginal birth trial, and 7.26 after elective caesarean section. Likewise, the mean lactate measurement was at 4.71mmol/L after vaginal birth versus 4.54 and 3.07 in the other two groups. Only neonates born after elective caesarean sections were transferred to intensive care (four cases). CONCLUSION: Vaginal breech delivery in case of a scarred uterus is possible, if each obstetrical situation is correctly studied to authorize a vaginal birth trial after a careful selection of patients and a strict management of labour. Vaginal birth does not seem to increase maternal and neonatal morbidity and mortality in this situation.

[A new prenatal diagnosis case of frontonasal dysplasia]. / Un nouveau cas de diagnostic anténatal de dysplasie frontonasale.

In a 30-year-old patient, the systematic second trimester fetal ultrasound discovered major facial abnormalities suggesting a frontonasal dysplasia (FND). The fetal karyotype was normal but no additional genetic testing was performed. Fetal MRI found an important hypertelorism and an asymmetric cerebral ventricle, with a partially visualized corpus callosum. After several consultations and interviews, the couple made a formal demand for pregnancy interruption, which was approved. Fetal pathologic examination confirmed the diagnosis of FND with no other major associated malformation. This rare pathology results from a midline facial dysgraphia comprising a hypertelorism, a large nasal base, a large clefted nose tip and, a V-shaped hair implantation on the forehead. It often occurs sporadically, of unknown cause, related to a defect in the embryonic nasal capsule development. Syndromic forms have been described with cerebral lesions and possible intellectual deficiency. Consequently, a long and difficult surgical management is necessary, at the expense of poor aesthetic outcome. Seven cases of prenatally diagnosed FND have been reported in the literature, three of which had 3D ultrasound.

[Operative delivery data in France for 2007: results of a national survey within teaching hospitals]. / Données 2007 de l'extraction instrumentale en France: résultats d'une enquête nationale auprès de l'ensemble des centres hospitalo-universitaires.

AIM: Clinical Practice Guidelines of the French College of Gynecologists and Obstetricians concerning operative deliveries were published in December 2008. That is why a national survey was performed for the year 2007 so as to obtain an inventory of obstetrical practices regarding the geographical distribution of the type of instrument used for operative deliveries following the level of each teaching hospital concerned. MATERIAL AND METHODS: We included in our study 49 teaching hospitals from metropolitan France and the overseas departments and territories. For the year 2007, we noted the number of operative deliveries, the type of instrument used, as well as the level of the maternity concerned with its total number of patients, births, cesarean sections, vaginal deliveries, and episiotomies. RESULTS: We obtained data from all 49 centres. The mean number of deliveries per year was 2203 for level I teaching hospitals, 2060 for level II and 2720 for level III, respectively. The rate of operative delivery was quite different from one centre to the other, ranging from 5.3 to 34.1% of all births. Similarly, for the type of instrument used, there existed clear geographical disparities although the notion of "School's instrument" was not as preeminent as before since most centres used at least two instruments. Moreover, the rate of cesarean varied from 9 to 29.5% (all levels concerned) with a national mean rate of 20.7% for teaching hospitals. Finally, mean rate of episiotomies ranged from 3.6 to 60%. DISCUSSION: This study showed that important differences existed between teaching hospitals in the use of instruments and that obstetrical practices are far from being uniform. However, in 2007, the routine use of more than one instrument in each centre was most usual, as opposed to the situation some decades ago. The use of obstetrical vacuum extractors has been largely disseminated. Each of the three types of instruments has specific indications and mastering at least two instruments seems more secure in the management of the numerous obstetrical situations. It is up to teaching hospitals to make sure that the use of at least two instruments is taught for operative deliveries. The recent publication of Clinical Practice Guidelines would probably help in standardizing operative deliveries in years to come.

[Comparing fetal and maternal morbidities between operative deliveries by Teissier's spatulas and Minicup vacuum extractor]. / Morbidité materno-foetale liée à l'extraction instrumentale par spatules de Teissier. Etude comparative à la ventouse obstétricale de type Minicup.

OBJECTIVE: To compare fetal and maternal morbidities between operative deliveries by long Teissier's spatulas and Minicup vacuum extractor. MATERIAL AND METHODS: A retrospective study was conducted from January 2003 to July 2008 at the maternity ward, Besançon teaching hospital. Operative deliveries in term cephalic singleton pregnancies performed by Teissier's spatulas (case group) were compared to previous deliveries by vacuum extractor Minicup (control group). RESULTS: During the study period, 69 operative deliveries by Teissier's spatulas have been performed. No significant difference was found between the two groups in terms of maternal characteristics. Two third-degree perineal tears occurred following delivery by Teissier's spatulas with no third-degree tear in the vacuum extractor group (p = ns). The episiotomy rate in the Teissier's spatulas group was 15,9% compared to 11.6% in the vacuum extractor group (p = ns). Duration of operative delivery was significantly shorter in the Teissier's spatulas group (3.4 min vs 4.95 min; p = 0.007). Fetal morbidity was identical in the two groups. CONCLUSION: This study found no significant difference in terms of fetal and maternal morbidities between operative deliveries by Teissier's spatulas and vacuum extractor. Moreover, as opposed to Thierry's spatulas, the long Tessier spatulas can be adequately used in accordance with patient's wish and practice guidelines recommending a policy of restrictive episiotomy. However, a larger study is needed to confirm these preliminary results.

[Term-breech presentation: predictive factors of cesarean section for vaginal-birth failure]. / Présentation du siège à terme: facteurs prédictifs de césarienne en cours de travail.

OBJECTIVES: In our maternity ward, vaginal-breech birth is favoured when the protocol for patient's eligibility is respected. But in our practice, 20% patients have a cesarean section during labor for vaginal-birth failure, with a higher rate of neonatal and maternal morbidities. This study tried to consider if some obstetrical elements, not usually used, could help select the candidates in a more efficient way. PATIENTS AND METHODS: This retrospective study included all the singleton-breech deliveries with a gestational age over 37 weeks in our maternity ward from 1994 to 2004. An analysis of obstetrical elements, available before and during labour, has been carried out. RESULTS: Three hundred and seventy-six deliveries were indexed for a vaginal-birth trial. We carried out a cesarean section in 21.3% cases. We have found five obstetrical elements, not used in the vaginal birth protocol, which were significant risk factors for a cesarean section: nulliparity (OR=0.25 [0.11-0.57]), maternal height (OR=0.56 [0.30-1.03]), ultrasound estimated fetal weight (OR=7.76 [2.29-26.28]), fundal height (OR=3.9 [2.41-8.62]) and dystocia in first stage of labour (OR=4.97 [2.67-9.25]). DISCUSSION: A cesarean section during labor is responsible for a high-morbidity rate. We have to reduce this obstetrical event, especially in breech presentation, by a better selection of patients. From this study, we have created a statistical model to screen patients, but we have to lead a prospective study to validate it.

[Diagnosis of myocarditis: description and assessment of available methods]. / Diagnostik der Myokarditis: Darstellung und Bewertung der verfügbaren Methoden.

Myocarditis is a common disease in all age groups. Correct diagnosis of myocarditis is difficult, but of clinical and scientific importance. It is the aim of this review to describe and evaluate diagnostic possibilities. It is not possible to make a definitive diagnosis of myocarditis by electrocardiography, laboratory tests or echocardiography. Nor can techniques of nuclear medicine or coronary angiography provide an unequivocal diagnosis of myocarditis. Myocarditis can be diagnosed with certainty only by endomyocardial biopsy, which must be examined by histological, immunohistological and molecular techniques to obtain maximal sensitivity. But optimal diagnosis of a biopsy is subject to the problem of sampling error. Furthermore, myocardial biopsy is in practice used only rarely, despite a low complication rate. Thus the diagnosis of myocarditis is often based merely on suspicion. The limitations of standard methods employed so far have made cardiac magnetic resonance imaging (CMR) a valuable new additional test when there is the clinical suspicion of myocarditis. A myocardial biopsy will often reveal myocarditis in patients with cardiac symptoms and CMRI findings typical of myocarditis, especially if the biopsy was obtained near the area of contrast enhancement in the CMRI. CMRI can also be used for noninvasive and low-risk follow-up of functional parameters and tissue damage.

[The association of continuous peridural anesthesia with general anesthesia. Apropos of 2 accidents]. / Association anesthésie péridurale continue et anesthésie générale. A propos de deux accidents.

Continuous lumbar epidural anaesthesia combined with light general anaesthesia provides optimal anaesthetic conditions to realize major lower abdominal or pelvic surgical cases. However this technique may cause haemodynamic alterations due to the important vasoplegia and to the potential myocardial toxicity of the local anaesthetics. The authors report two accidents associated with this technique, one of them with lethal outcome.

Structure of the mouse gene encoding parathyroid hormone-related peptide.

The parathyroid hormone-related peptide (PTHRP) was initially isolated from tumors associated with the syndrome of humoral hypercalcemia of malignancy. The human PTHRP gene is a complex transcriptional unit which uses multiple promoters and contains alternatively spliced 3' exons that result in mRNAs encoding three different deduced products. We report here the structure of the mouse PTHRP gene. The mouse gene has a considerably simpler organization than its human counterpart. This organization includes a single 3' exon and an apparent single 3' splicing pathway, leading to an mRNA encoding a 139-amino acid mature PTHRP. In addition, the mouse gene appears to be predominantly under the control of a short proximal promoter element. By RNase protection analysis, we identified PTHRP mRNA in specimens prepared from a variety of normal rodent tissues, including a number of tissues not previously recognized as sites of PTHRP gene expression.

Identification of an up-stream promoter of the human parathyroid hormone-related peptide gene.

Previous evidence has suggested that the human PTH-related peptide (PTHRP) gene uses two promoters, one a short down-stream element lying immediately between two 5' exons (1 and 2) and a second lying in an unknown up-stream location. We approached identification of the up-stream element in three steps. First, Northern analysis carried out using progressively 5' fragments of the gene as probes identified a candidate region some 2.5 kilobases up-stream of exon 1. Second, a battery of overlapping 5' cRNA probes was used in RNase protection experiments to identify two previously unrecognized exons, 212 and 93 basepairs in length (termed exons 1A and 1B to distinguish them from the previously designated exon 1, which was termed exon 1C). Third, primer extension experiments were performed with oligonucleotides complementary to each of the 5' exonic sequences. These experiments identified a transcription start site up-stream of exon 1A and also demonstrated that the 5' exons of the PTHRP gene could be spliced together in several combinations. The up-stream promoter element contains a TATA box, but does not otherwise resemble the down-stream PTHRP gene promoter or the PTH gene promoter. We conclude that the human PTHRP gene contains eight exons spanning more than 15 kilobases of genomic DNA, with promoter elements lying immediately up-stream of exons 1A and 2. The identification of these elements will permit functional analysis of their roles in mediating tissue- and tumor-specific PTHRP gene expression.

Regulation of parathyroid hormone-related peptide gene expression by cycloheximide.

A novel parathyroid hormone-related peptide (PTHRP) has been isolated from tumors associated with the syndrome of humoral hypercalcemia of malignancy. The human PTHRP gene appears to use multiple promoters and contains alternatively spliced 3' exons which give rise to three PTHRP mRNA classes, each bearing multiple copies of an AU motif that has been associated with mRNA instability. We report here that inhibition of protein synthesis leads to the super-induction of PTHRP mRNA expression in a number of human and rat cell lines. This phenomenon was found to reflect both an increase in the rate of PTHRP gene transcription and a stabilization of PTHRP mRNAs. The transcriptional mechanism appears to preferentially involve the activity of a short downstream promoter of the gene, which is presumed to be regulated by a labile repressor protein. Our findings indicate that both transcriptional and posttranscriptional mechanisms may be important control points in the regulation of PTHRP expression in normal and malignant cells.

Glucocorticoid regulation of parathyroid hormone-related peptide gene transcription in a human neuroendocrine cell line.

A PTH-related peptide (PTHRP) has been identified and its cDNA cloned from tumors associated with the syndrome of humoral hypercalcemia of malignancy. The PTHRP and PTH genes appear to represent members of a gene family. Whereas the PTH gene is expressed exclusively in the parathyroids, the PTHRP gene appears to be widely expressed, but little is known concerning the regulation of its expression in any site. We studied the regulation of PTHRP gene expression in a human carcinoid cell line (NCI-H727) which has neuroendocrine features and also produces calcitonin, calcitonin gene-related peptide, and chromogranin-A. We found that the synthetic glucocorticoid triamcinolone produced time- and dose-dependent decreases in steady state PTHRP and calcitonin mRNA levels in NCI-H727 cells. This effect was blocked by the competitive glucocorticoid inhibitor RU-486. Messenger RNA stability and transcription run-off experiments revealed that triamcinolone decreased PTHRP and calcitonin expression by repressing the transcription rates of both genes.

Expression of transcripts encoding a parathyroid hormone-related peptide in abnormal human parathyroid tissues.

A PTH-related peptide (PTHRP) has been identified and its cDNA cloned from human tumors associated with the syndrome of humoral hypercalcemia of malignancy. The human PTHRP gene has been recently isolated and found to be a complex transcriptional unit using multiple promoters and containing alternatively spliced 3' exons which result in three mRNA classes, each class encoding a PTHRP with a unique carboxy-terminus. The PTHRP gene appears to be expressed in a number of normal tissues, and PTHRP transcripts have been previously reported to be overexpressed in a small sample of human parathyroid adenomas. In the present study we surveyed RNA prepared from a total of 60 abnormal human parathyroid glands for PTHRP gene expression using a combination of Northern blotting and RNase protection techniques. Apparent overexpression of PTHRP mRNA was observed in two thirds of parathyroid adenomas, whereas no overexpression was found in 7 examples of sporadic primary hyperplasia, 5 examples of secondary hyperplasia, and 3 examples of parathyroid carcinoma. Apparent overexpression was also observed in 1 of 4 cases of multiple endocrine neoplasia type 1, 1 of 2 examples of multiple endocrine neoplasia type 2, and 1 gland considered to represent tertiary hyperparathyroidism. Northern analysis of poly(A)+ RNA prepared from three representative adenomas using region-specific probes indicated that two putative promoters are used and revealed a pattern of preferential splicing of transcripts to include the most distal 3' exon. These findings suggest that the PTHRP gene is commonly overexpressed in adenomatous parathyroid glands, but not in sporadic primary hyperplasia, that this overexpression does not seem to be dependent on the use of a single specific promoter, and that adenomatous parathyroid cells appear to preferentially use one of several alternative splicing pathways. It is presently not known whether PTHRP is secreted by abnormal parathyroid tissues and, if so, in what form.