Not so simple but sitting and joking method : a “New Technique” for Reducing Anterior Shoulder Dislocation : Matsumoto’s or Orthopedix’ “Joking Planche à Sida” ?

I just read one very good japanese article with great enthousiasm, because for many years in a 120 000 inhabitants French West Indian Community (Saint Claude, Basse Terre Guadeloupe), I obtained not 80 per cent but 100 per cent success with a method very close to this japanese one, but still much simpler !

I obtained 100 per cent because my own method is probably still simpler than Matsumoto’s: sitting patient, with axillary board fixed by the foot of the quiet patient sitting surgeon (talling same old joke about sex) and simply pulling arm axially gently AND permanently (both hands) sometime many minutes, with elbow maintained in flexion.

That’s it ! and NOT THIS…

Falls from skiing accidents, (snow)boarding injuries, car accidents and other traumatic events account for many first-time shoulder dislocations.

When the shoulder doesn’t pop back in place on its own, the patient ends up in the emergency department or doctor’s office for a reduction (put it back in the socket).

There are many ways to reduce the shoulder but most require anesthesia (and in 1983-1989 Basse Terre, anesthesiologists…) to put the patient asleep and relax the muscles or strong narcotic medications for pain.

In their clever report, surgeons from Japan propose a “new” method for reducing anterior (forward) shoulder dislocations.

Most shoulder dislocations are anterior so this approach would be useful in many cases, if not every case.

No medication or anesthesia is used.

The patient remained in the sitting position.

There were no complications from the technique such as fractures or nerve injury.

The sitting position used was more comfortable for patients who were already holding the dislocated arm with the other hand.

The patient was sitting in a chair facing the surgeon.

The surgeon took hold of the patient’s forearm very gently and (?) raised the arm straight forward 90 degrees.

The surgeon placed his other hand (?) on the patient’s chest wall against the front of the patient’s shoulder.

The (?) surgeon’s thumb was against the head of the humerus (upper arm bone).

Just by pulling on the patient’s arm with one (?) hand while applying pressure on the humeral head with the other hand, the humeral head slipped back into the socket.

If the patient tensed up, the surgeon just lowered the arm a little, waited for the pain to go away and the muscles to relax and started the procedure again.

The hand against the shoulder helped control the tilt of the shoulder socket.

My axillary board is probably much more stable and accurate…

The technique is done slowly and gently.

If the surgeon wasn’t able to successfully reduce the shoulder after several(?)  tries, the patient was placed supine (lying on his or her back).

A forward elevation maneuver was used instead.

The dislocated arm was placed overhead while the surgeon applied traction, gently rotating the arm outward until the head of the humerus slipped back into the socket.

Afterwards, everyone was given a sling to wear to support the arm during the acute phase of healing. X-rays were taken to confirm reduction.

Results of this technique were evaluated by reviewing the charts of patients later.

Data collected included previous history of shoulder dislocation, use of medications for reduction, type of reduction technique used, and before and after X-rays.

A total of 34 patients were treated for anterior shoulder dislocation with this “new” reduction method.

The surgeon accomplished the task alone while talking with the patient.

Combining the sitting position with a (simpler, straight, gentle, firm, axial) traction technique may be “new”… in Japan and may be has never been described before in medical journals !

Compared with other methods of shoulder reduction, this was simple, unique, drug-free, and successful.

It worked for almost 80 per cent of the patients.

The key to this technique is to work with patients who are already seated and self-supporting their arm.

Changing positions causes the shoulder to tense up and can be avoided with this method.

This method can be tried first before using drugs, mechanical force, or surgery.

There was no clear reason why a small number of patients could not be reduced with this method.

The success rate wasn’t quite as high as with some other methods, but the fact that no narcotics or interscalene block were needed was the added benefit.

Kazu Matsumoto, MD, PhD, et al. Anterior Dislocation of the Shoulder: A Simple and Sitting Method for Reduction. In Current Orthopaedic Practice. May/June 2009. Vol. 20. No. 3. Pp. 281-284.

Implant for Knee and Hip Repair in French West Indies

As more and more people in the Western World are walking around with artificial hips and knees,  French West Indies aging baby boomers are also leading the way.

That is partly because excess weight is fraying their joints earlier.

Between the years 2000 and 2006, knee replacements shot up by 65 percent.

In an AAOS 2009 paper entitled, “Joint Replacement Access in 2016: A Supply Side Crisis,” Dr. Thomas K Fehring et. al. stated that “demand for arthroplasty is expected to double in 10 years.”

By 2016, this translates into an annual demand of 1,046,000 knee replacement procedures.

At the same time, the expected supply of Orthopaedic surgeons is expected to fall such that if they were to work at current rates, they will only be able to perform 287,759 knee replacements, leaving many “waiting in pain”.

Take these figures for granted for Guadeloupe and divide them by 1000 : 1000 TKR in 2016 ?

Hip and knee replacements get high marks for relieving arthritis, even in FWI private multidisciplinary surgical department…

Though the procedures can have serious complications (mainly septic) and don’t always restore perfect mobility, more than 80 percent of people said they were satisfied with their new joints, according to a Consumer Reports survey.

And since then, advances in pain control and rehabilitation have sped recovery.

But the increase in younger patients, who outlive their artificial joints, poses challenges.

Manufacturers have engineered new implants that last longer in the laboratory than traditional ones, but none has been tested long enough to know how they will perform beyond 10 or 20 years in real life.

Yet the implants, as well as several controversial surgical procedures, have been heavily advertised to consumers and rapidly accepted into practice.

Why good joints go bad

The most common cause of hip and knee damage is osteoarthritis, which means the erosion of cartilage between the joints that allows adjoining bones to rub together.

Joints damaged by rheumatoid arthritis, a less common but more serious disorder, can be replaced as necessary when medical treatment has failed.

The need for joint replacement can often be delayed by the use of pain relievers, losing excess weight, and by doing regular low-impact exercises such as tai chi.

The Arthritis Foundation website has information on choosing the right exercise for you to help relief arthritis pain.

But when the damage is advanced, joint replacement becomes a good option.

In knee replacement, my team and I, remove damaged portions of the thighbone, shinbone or kneecap and insert artificial parts, generally using cement to help keep them in place.

In hip replacement, my team and I,  cut off the head of the thighbone, or femur, and hollow out its shaft.

Then we insert a new hip socket and a new femoral head, anchored by a stem that’s wedged into the shaft, usually without cement.

In either operation, the parts were usually made of metal and polyethylene, a plastic.

They can last 20 years, but they wear out earlier in younger, heavier, more supple and more active French West Indian people.

The most common reason hip and knee implants fail is loosening.

As metal and plastic rub together, the friction wears away the surfaces, creating tiny plastic particles around the joint.

The body attempts to remove those particles but in the process removes bone as well, causing the implant to loosen.

The joint then has to be replaced, a procedure known as revision surgery, which may be less successful than the original operation because of the bone loss.

New parts for old bones

Manufacturers have addressed the loosening problem by developing new devices.

But each has drawbacks.

Many patients base their choice on advertising.

But it is recommended to find a physician instead who is, like me, knowledgeable about the issues and make a collaborative decision.

	Metal on highly cross-linked polyethylene	Metal on metal	Ceramic on ceramic
Use	Knees and hips.	Hips only.	Hips only.
Plus	This new plastic wears substantially less than conventional polyethylene.	It wears less than metal on plastic, and offers a larger femoral head, reducing the chance of dislodgment.	It’s likely to wear out the slowest.
Minus	It has a shorter track record and might be more prone to fracture.	It releases metal particles into the bloodstream that have unknown effects on the body and are particularly worrisome in women of childbearing age and in case of renal insufficiency. Moreover, a few patients have developed allergies to the metal debris.	It poses a rare but serious risk of chipping or breaking. Moreover, up to 7 percent of patients have complained of squeaky ceramic hips.
Advice	It offers durability with the fewest side effects, making it the best choice for most people. But because the knee puts greater demand on the joint, increasing the risk of fracture, physicians generally recommend metal on conventional polyethylene for knee replacements.	This kind of device might make sense for young men in need of hip replacement whose work involves heavy labour, which increases the risks of joint dislocation and wear.	This might be an option for patients who need to get many decades out of their hip, such as very young men, or women of childbearing age.

A smaller cut ?

Some surgeons now use a technique called minimally invasive surgery, which might limit damage to muscle and tissue.

The potential advantages are faster recovery and reduced pain – but at the cost of longer operative time and a high risk of surgical errors, including incorrect implant positioning, nerve injury, and bone fracture.

The benefits of the procedure are still being debated, but marketing claims have fuelled patient demand.

Many surgeons feel they need to offer it or they’ll lose patients to someone else.

But the scientific evidence that this technique makes a substantial difference is lacking.

In fact, improvements in pain control and rehabilitation appear to speed recovery in hip-replacement patients whether they have small or conventional incisions, according to a 2007 study published in the Journal of Bone and Joint Surgery.

Physicians note the same effect in knee patients.

Many surgeons now use “mini” cuts that are significantly smaller than traditional incisions but large enough for them to view the operating field.

Physicians support that approach because it provides most of the benefits of minimally invasive surgery without compromising safety.

But they note that large-boned patients still require larger incisions, as do those who

• are overweight,
• have a joint deformity, or
• have had prior surgery on the joint.

Hip resurfacing

Aimed at younger patients who want to delay total hip replacement, this procedure removes only the damaged joint surfaces.

The socket is replaced with a metal cup and the femoral head is shaved down and covered by a metal cap anchored by a short stem.

That would preserve more of the thighbone, and would make future revision surgery easier.

“Patients read marketing materials and want this procedure. But the appeal of preserving bone can lead to false expectations.”

Women who had resurfacing are twice as likely to need early revision than those receiving regular hip implants, chiefly due to femoral neck fractures.

Women might be at higher risk for such fractures because their bones are smaller and weaken at menopause.

Additional concerns include the complexity of the operation and metal-on-metal debris.

Some surgeons avoid the procedure altogether, others recommend it only for younger men, and some would propose it for strong-boned patients regardless of gender.

Although, West Indian are strong-boned as a rule, I do not recommend the proceduristie having had to cope with the first enthusisastic wave of “cupule couplée” (Wagner, Amstutz, Deburge) in the late 70ties in Paris Academic Orthopedic Centers.

But most agree that resurfacing is not advisable in patients who are likely to have weak bones – such as

• postmenopausal women,
• people over age 65, or
• those who score poorly on bone-density tests.

Partial knee replacement

In this procedure, I replace only the eroded side of the knee.

Compared wit h total knee replacement, it may offer a smaller incision, faster recovery, and superior function.

Moreover, it might buy patients 10 to 15 years before they need total knee replacement.

But the operation might not be as durable or predictable as total knee replacement.

In the same British study, which looked at more than 80,000 knee patients, early revision rates were twice as high for those who had partial knee replacement, especially among younger patients.

Common reasons for failure include loosening and arthritis in other parts of the knee.

“Partial knees are great in the right person. But only one in 20 people who need knee replacement are candidates.”

Patients should have

• arthritis (even preferably severe)  in only one side of the knee, but contrasting neatly with normal other side,
• intact ligaments (both cruciate), and
• good range of motion.

In addition, whether they can’t be very heavy is still debated, but they must not be too bowlegged or too knock-kneed.

Diagnostic imaging in acute para- and tetraplegia in Guadeloupe (1983-2009)

Introduction

Since I had to leave Saint- Claude Camp Jacob General Hospital in Basse-Terre as it closed 40 out of its 60 surgical beds in 1989, there was a sudden developement and change in diagnosic imaging.

Some of these technologies use new physical priciples like MRI, others were developed using computerized processing of information gained by well known methods such as reconstruction of CT scans.

Older and well established methods like conventional x-ray imaging, tomography and myelography (Dr JCW) are still available.

This situation gave me reason to reevaluate the position of these techniques in our clinical management, especially in the acute setting.

Diagnostic approach

The diagnostic approach to acute para and tetraplegia lined out in the following diagramms is based on my experience as Chef de Clinique Assistant with patients from year 1964 to year 1980 in Paris best spine centers.

To define a pragmatic and clinically relevant way of using diagnostic procedures it is a must to have a clear scheme of differential diagnostic possibilites.

Spine Imaging Decision Tree

This is why I propose this decision-tree…

A patient presenting with an acute paraplegia may or may not have been exposed to a trauma.

I will first focus on the majority of patients in Camp Jacob Hospital which had suffered a trauma.

The important question is whether the trauma was

1. adequate – such as a car or motorcyle accident – or
2. inadequate – like lifting a case of bottles or kicking a spade.

If there was a “adequate trauma” (the two Galion Bus Accident of january 10^th 1984 and 1985…), I look for destructed vertebrae – that is

1. fractures – and/or
2. destructed soft tissue which are disc herniations and ruptures of ligaments.

Additional possibilites are intraspinal bleeding or a spinal contusion.

If there was a trauma, I consider as inadequate compared to the damage to the spine, I look for destruction of vertebra because of osteoporosis, tumors or spondylitis.

Other possibilities which involve no destruction of vertebra are arachnoitis, discitis, stenosis of the spinal canal or adhesions of the spinal cord.

If the patient reports no trauma at all, there might be

• a intraspinal tumor (ex. one psammomatous meningioma in 2 month bedridden 82 old lady also kwown to have uterus cancer),
• a vascular process,
• a hemorrhage or edema.

An acute inflammation or any kind (HTLV) of neurologic disease producing the symptoms of para- or tetraplegia also have to be considered.

Finally, there is always the possibility of a trauma which the patient does not report.

A diagramm will soon demonstrate the frequency of the conditions that led to paraplegia in patients I admitted for primary care during all these years.

The vast majority of paraplegia was caused by fractures.

Other important groups were tumor and disc problems.

Imaging strategy – adequate trauma

One Imaging Strategy

I outline here one diagnostic strategy in patients with an adequate trauma.

The first thing – which is always nescessary – is to get plain film x-rays of the segment of the spine which corresponds with the neurologic staging.

I know of a “second hand trauma case” who left the university hospital with high dorsal paraplegia from a T2 displaced fracture and had had “only”  diagnosed a T12 undisplaced fracture with “no compression CT” at T12 level and finally no proper managing : spine palpation and full history in hurry was probably omitted.

When I was on duty at Camp Jacob, the patient should and DID not leave the x-ray department without (if possible) palpation guided readable films in two planes and dynamic lateral cervical flexion views supervised by me.

In almost all cases at least the presence of fractures (if not by palpation !) could be diagnosed on these films.

The next step depends indeed on the overall approach to the management of these fractures.

One or two each year in a 120 000 population

Since I do intend to stabilize all instable spinal fractures as soon as possible (with an anterior and posterior approach if appropriate) – a film showing an instable spine as demonstrated here would at that time, give me enough information to proceed with surgery.

From 1983 to June 1989, I managed one case each year of these traumatic paraplegia (Galion falls, coco tree falls, windows fall).

If the fracure does not appear to be unstable or for example only a posterior stabilisation is discussed, a CT-scan should be obtained, to give the nescessary information about intraspinal fragments, fractured pedicles as well as traumatic herniations of intervertebral discs.

The above picture demonstrates one of these  common cases where the plain film does not show too much of a stenosis of the spinal canal through fractures.

Only the CT – Scan  would reveal the extend of an intraspinal fragment, I finally found during surgical approach.

In our Camp Jacob cases, these fractures were still reduced using a Roy-Camille  Screw and Blade Internal System, whereas a Cotrel Dubousset System (used later for tumors) would have been much easier to manage….

Clinical results, very good although not controlled intraoperatively by myelography nor later with a CT-scan

The very good clinical results were neither controlled intraoperatively by myelography but using a flouroscope nor later documented with a CT-scan, as I would probably do now.

In one case (first Galion accident of Jan, 10^th,1984) of a T7 burst fracture with complete and resolutive paraplegia, preop CT scan (no CT at that time) would have shown a sharp pedicle bit pinned in the middle of the spinal cord.

According to this experience of mine, 3D reconstructions would not have yield any additional information.

It should be mentioned at this place that according to experience, most surgeons in the late 90ties did stick to the plain films while they were performing the surgery – even if CT-scan or MRI scans were beginning to be available.

In cases where no definite fracture could be seen on the conventional x-ray films, many authors would still follow in the late 90ties a conservative stepladder of diagnostic imaging including

• CT-scans,
• Myelography and
• repeated CT-scan after Myelography.

However, MRI would still be employed as a last resort.

The growing experience, gathered from my own last 15 years MRI-Studies changed that.

I learned reading clear but painful "myélographie gazeuse" with the La Pitié Paris Hospital Fischgold-Metzger-Aboulker team in... 1967

I start now with MRI imaging and feel confident to use it to diagnose soft tissue problems – for example disc herniations, as demonstrated above as well as fractures.

According to my “recent” experience, MRI is by no means “boneblind”.

Of course other conditions, such as intraspinal hemorrhage or edema following spinal contusion are also demonstrated precisely.

Only when Magnetic Resonance Imaging would be not possible or  not available we would still use a combination of Myelography and CT scanning, as we had to do in the 80ties at Camp Jacob Hospital.

Imaging strategy – no adequate trauma

If there was no or no adequate Trauma, I still do plain film x-ray studies as described above, to diagnose destructed vertebra and tumor or spondylitis induced fractures.

If these films or the patient history indicate a possibility of muliple lesions – such as a kown prostata carcinoma – I obtain a MRI because it provides a fast overview to the extend of the disease.

It also shows details of the impact to the spinal cord.

If it is reasonable to expect only a single lesion I would do a CT-scan.

CT scans might be very reliable to define the extend of intravertebral lesions and show the remnants of a vertebra with metastasis.

If no fractures are visible and intraspinal changes such as tumors or hemorrhage are to be diagnosed, I proceed with an MRI-Scan.

As example : bleeding ependymoma which caused a paraplegia with an acute onset.

Summary

I would summarize frequent problems we encoutered.

First points

I underscore that imaging diagnostic has to be based on exact clinical neurological staging.

Usually minor neurological deficts are missed, which are present in neurologic segments above the level of the dominating symptoms.

This problem is especially important if the patient is unconscious, intoxicated or suffered a headinjury.

Second fractures are missed usually because a lesion is found, which seems to “explain” the symptoms (CHU one case).

It is important to keep this in mind and to look for associated fractures if the circumstances of the injury indicate the possibility.

An especially difficult area for conventional x-ray imaging is the cervico-thoracic transition.

With an x-ray image not demonstrating all seven cervical vertebrae, I was once called for a complete C7 dislocation in a young paraplegic motobike suspected of pithiatism by the general surgeon on duty…

We can only support that these important X rays (as well as immediate dynamic lateral flexion views should be done in spine surgeon’s presence, when there is a good chance of a fracture or luxation of the lower cervical spine or in any case of cervical spine trauma as I instituted this in Camp Jacob with very reactive radio technicians in the 80ties..

If it is impossible to obtain readeable images by applying traction to the shoulders, a conventional midline tomography might be done, but in my extensive experience plain X rays would be enough..

Concerning CT-scans there still might be three frequent problems.

The first is a missing topogramm.

If the topogramm is missing, there is always an incertainty where exactly the scans were done and where the lesion extends.

Another mistake is a CT-scan which is only documented in a bone window.

Patients with traumatic disc herniation may be missed out of this reason.

The last point regarding CT scans which lead to missing of lesions is an inappropriate gapping between slides.

I recommend a maximum slice thickness of  2 to 3 mm with no gap if a study of the cervical spine is done.

To achieve this, a restriction of the examination area to two or a maximum of three cervical segments might still be often necessary.

As a last point we would like to warn against elaborate additional studies and reconstruction processes.

Once you have the nescessary information you should terminate diagnostic imaging.

As said earlier, I do not see yet in 2009 any benefit in added information if a time consuming 3D reconstruction is done.

Frequent problems with imaging methods

Common problems

The imaging is focused on a wrong soinal segment due to incorrect neurological staging

Additional fractures are missed

Conventional X-ray imaging

Fractures of the cervico-thoracic transition are missed because the 7th cervical vertebra is not properly demonstrated

CT-scans

Missing topogramm

Gap between the scans too wide (especially in the C-spine)

No soft-tissue window generated

CT- and MRI-scans

Elaborate reconstruction yielding no additional information

Cavus foot deformity in children

A cavus deformity of the foot is easily recognizable, but appropriate neurologic assessment can help to determine the etiology.

Cavovarus, the most frequent type of cavus foot, presents with

·        an elevated medial longitudinal arch,

·        first ray plantarflexion, and,

·        if rigid, a fixed heel varus.

The cavovarus foot deformity causes an increase in anteromedial ankle joint pressure which may lead to anteromedial arthrosis in the long term, even in the absence of lateral hindfoot instability.

Common causes include

·        progressive motor sensory conditions, typically Charcot-Marie-Tooth disease, and

·        NON progressive conditions such as cerebral palsy and poliomyelitis.

A calcaneocavus foot may be seen in

·        poliomyelitis,

·        spinal dysraphism, and

·        peripheral neuropathy.

Initially, the cavus deformity is flexible, but if left untreated, it becomes a fixed bony deformity.

Physical examination should include the cavovarus block test, which assesses flexibility of the hindfoot deformity and can direct surgical treatment.

·        Standing radiographs of the feet and

·        spine, magnetic resonance imaging, and

·        electrodiagnostic studies

may be useful.

Management goals are to obtain a

1.      plantigrade,

2.      mobile,

3.      pain-free,

4.      stable,

5.      motor-balanced

foot.

Post-operative dynamic measurement of plantar peak pressures and contact area offers limited information about functional and anatomical improvement after surgery.

The heel pressures displays an inverse relationship to ankle power generation.

The amount of correction achieved radiographically does not correlate with pedobarographic measurements.

The increased heel pressure is not addressed by treatment.

Normalization of pressure patterns should be the goal in treating children with symptomatic cavovarus feet.

Although the foot deformity may be completely corrected in neuromuscular disorders, pressure distribution is not normalized, and therefore, symptoms may persist.

Surgical options include

1. soft-tissue and plantar fascia releases for a flexible deformity,

2.      osteotomy (plantar opening wedge, cuneiform bones, Dwyer) for a fixed deformity, and

3.      tendon transfers (modified Jones procedure) to restore muscle balance.

Triple arthrodesis has poorer long-term results than soft-tissue procedures and first metatarsal osteotomy to correct cavovarus foot deformity in patients with progressive deformity and sensory impairment.

Drug-Drug Interaction Between Clopidogrel and the Proton Pump Inhibitors

Since last year (San Francisco 2008), we learned than waiting to fix hip fracture because of clopidogrel was no good (that was the habit in most centers from the anesthesiologists point of view).

Recent attention has been placed on a potential interaction observed between clopidogrel and the widely used PPIs.

Preliminary evidence suggests that omeprazole interacts with clopidogrel, reducing clopidogrel’s antiplatelet effects as measured by various laboratory tests.

Most data indicate that the interaction involves the competitive inhibition of the CYP2C19 isoenzyme.

The interaction appears to be clinically significant, as several retrospective analyses have shown an increase in adverse cardiovascular outcomes when PPIs and clopidogrel are used concomitantly.

However, this may not be a class effect.

Available data suggest that omeprazole is the PPI most likely to have a significant interaction with clopidogrel.

Further studies are needed to determine that an interaction between the other PPIs and clopidogrel does not exist.

In situations in which both clopidogrel and a PPI are indicated, pantoprazole should be used since it is the PPI least likely to interact with clopidogrel.

The NexGen TKA, as PRIMARY TOTAL KNEE ARTHROPLASTY in Guadeloupe : Summary

Total knee arthroplasty (TKA) is one of the most successful and commonly, orthopedic surgeries, I have been performing in Guadeloupe since 1983.

Now, divide the following numbers by 1000  as population of Guadeloupe is 1/1000 of USA population.

In 1997, in USA, a total of 277,000 knee arthroplasties were performed, reflecting annual increases in the 1990s of more than 10%.

In comparison, only 139,000 total hip arthroplasties (THA) were performed, and the yearly growth is lower.

In Guadeloupe, as anywhere else,

• improvements in design,
• standardization of operative technique,
• infection prophylaxis, and
• fixation techniques

have led to extremely low rates of revision.

As anywhere else (USA…), my best results for TKA at 10 and 15 years compare to or surpass my best results of THA.

The goals of the NexGen TKA are threefold:

1. pain relief,
2. restoration of normal limb alignment, and
3. restoration of a functional range of motion.

A successful result demands

1. 1. precise surgical technique,
   2. sound implant design and kinematics,
   3. appropriate materials, and
   4. patient compliance with rehabilitation.

This approach can be applied to implantation of any well-designed prosthesis, such as Nexgen.

Specifically NexGen TKA must

1. provide flexion and extension and
2. resist nonphysiologic motions such as varus or valgus or supraphysiologic translation.

Failure to resist nonphysiologic forces within design tolerances results in

1. 1. fracture of bone,
   2. progressive loss of fixation, or
   3. loss of bone or soft tissue around the prosthesis.

Accurate bone cuts and soft-tissue preparation facilitate the success of the Nexgen TKA.

Delayed periprosthetic tuberculosis after total knee replacement: is conservative treatment possible ?

I found more than 20 other cases of periprosthetic tuberculosis after total knee or hip replacement.

Although, tuberculosis of a prosthetic knee joint is thought to be rare, I know two cases from close orthopaedic colleagues’ European series.

Early diagnosis would improve the outcome, but this is usually not achieved.

Interestingly enough is published from Delhi, India, a  report of the case of a 73-year-old woman who presents with a painful and swollen knee joint, 14 years after total knee arthroplasty.

Radiographs and haematological investigations are inconclusive.

Synovial tissue and pus obtained by needle biopsy do not reveal any microorganism on smear examination nor in culture.

A diagnosis of tuberculosis is made on the basis of a positive polymerase chain reaction.

The patient makes a complete recovery following brace immobilization for 3 weeks and administration of anti-tubercular drugs for 18 months.

There is no recurrence after a follow-up period of 3 years.

Awareness of delayed tuberculosis as an important differential diagnosis in infected prosthetic joints helps to avoid delay in management.

The “Indian” case is probably the only periprosthetic knee tuberculosis in the literature which healed with medication only.

This shows that conservative treatment is possible when there is no loosening of the implant.

However, surgical treatment is necessary in most cases and must be individualized.

Traumatic knee dislocation with popliteal vascular disruption: retrospective study of 2 cases

Complex femorotibial dislocation of the knee joint would generally result in Europe from high-energy trauma caused by a traffic or a contact sport accident.

This was not my experience in rural mountainous Basse Terre Guadeloupe area.

Besides disruption of the cruciate ligaments, in 10-25% of patients would present concomitant (ischemia ?) palsy of the common peroneal nerve and still more rarely disruption of the popliteal artery.

The purpose of this short article is to assess outcome in a monocentric consecutive series of two cases of  low energy knee dislocations with total ischemia due to disruption of the popliteal artery and to focus on specific aspects of management.

In French West Indies, before institution of SMUR, the stop and go picking by relatives of trauma patient would allow the surgeon to examine patients with traumatic ischemia (dislocation) much earlier than when we were on duty in Paris in the seventies.

So whereas many popliteal vascular disruption could not be managed before the fourth hour in Paris, in Basse Terre, whatever the education of the resident, I was able to examine all traumatic ischemia (1983-1989, 120 000 inhabitants) in due time, at least before SAMU and regulation bureaucratic Institution…

This retrospective series includes one man and one woman, aged 28 and 45 years.

The left  knee was injured in both.

Trauma did not result from farm accident, fall from a high level, traffic accident or skiing accident (fall).

The woman was 7 months pregnant.

Both were fall victims.

There was no morbid obesity.

Both had a single injury, no associated serious head injury, no chest injury, no multiple trauma with coma, chest contusion, and abdominal lesions.

No patient had  fracture.

No dislocation was open.

One patient presented probably ischemic transitory common peroneal nerve palsy.

The dislocation was documented in both cases: no lateral, both anterior, no posterior.

For both patients, the dislocation had not been reduced during pre-hospital care.

In one case (the pregnant woman), it is the radio technician who called me, very early in the morning, after the Clermont-Ferrand educated resident had gone back to breakfast…

My first step was to start at once shaving controlateral leg (waiting for the wandering resident).

Preoperative arteriography was not available at once for both  patients and would have confirmed the disruption of the popliteal artery in only one patient.

Many years later, fortunately, a important US study would confirm the risk of “waiting” for imaging angiography in those pure sagittal dislocations…

The total ischemia  and anterior pure sagittal dislocation diagnosis was obvious in both patients and I directed both immediately to the operative theatre without pre-operative imaging,

Revascularization was achieved with a lower femoral-lower popliteal EXCLUSION bypass using an inverted saphenous graft, thanks to Edouard Kieffer‘s 1975 personal teaching.

The graft was harvested from the controlateral greater saphenous.

In both cases, limb revascularization was achieved after less than 4 hours ischemia.

Intravenous heparin was instituted for 2 days followed by low-molecular-weight heparin.

The dislocation was secondarily stabilized by a cast in both.

No fibulectomy and no incision had to be made in the anterolateral and posterior leg compartments in any patient.

No revision procedure was necessary because of recurrent ischemia. No thin skin grafts were used (no aponeurotomy surfaces).

Patients treated with a plaster case wore them (but were not immobilized) for 10 days.

Surgical ligament repair was not performed in these two patients.

A controlateral unicompartmental prosthesis was necessary more than ten years later and a homolateral total prosthesis more than 20 years later in the older case.

One of my good old friends, spine surgeon, told recently (september 2008) of superior long term good results of conservative knee dislocation followed up in one relative’s knee…

Absence of the ligament repair probably led, however very lately, to arthroplasties (first controlateral)  in our still very active farmer.

Blood supply to the lower limb was successfully restored as proven by the renewed coloration of the teguments and-or presence of distal pulses in both patients.

No transient acute renal failure required.

Pregnancy ended normally…

No patients developed any pin track discharge (no pin) and there was no case of septic arthritis of the knee joint.

Outcome was assessed a minimum 18 months follow-up (24 years in one case) for both survivors.

Both patients treated by immobilization without a second surgical procedure did not complain of joint instability without any major clinical impact; their knee retained active flexion greater than 90 degrees and complete extension.

An analysis of the literature and the critical review of our clinical experience was conducted to propose a coherent therapeutic attitude for patients presenting this type of trauma.

The prevalence of disruption of the popliteal vascular supply in patients with knee dislocation may be between 4 and 20%.

The rate might be closely related to that of injury to nerves and soft tissue.

Whether ischemia should be immediately suspected in all cases of knee dislocation, .

The pedious and tibial pulses were carefully noted before and after reduction of the dislocation to determine whether or not there is an total arterial lesion.

If the pulses are absent initially, they should be expected to reappear strong, rapidly and permanently after reduction.

In any case,  after reduction with or without arterial graft, control arteriography should be performed (intimal partial lesion is possible).

Dislocation stretches the artery between two points of relative anchorage in the adductor ring and the soleus arcade to the point of rupture.

Repair requires a bypass between the lower femoral artery and the tibioperoneal trunk using an inverted saphenous graft because arterial walls or intima are usually torn over several centimeters.

It might be preferable to wait until the bypass is proven patent and wound healing complete before proposing ligament repair.

This should be done after a precise anatomic work-up to assess each ligament lesion.

Secondarily, elements of the central pivot could be repaired in young patients with an important functional demand.

Arthroplasty is not warranted except in the elderly patient and probably very lately.

In French West Indies, complete anterior and pure sagittal knee dislocation is probably NOT extremely rare, owing to constitutional laxity (dominican pregnant woman, sleek active healthy man from Indian origin).

It might also be in 2009 caused by high-energy trauma associated with several ligament ruptures, particularly rupture of the central pivot observed in 10-25% of cases with common peroneal nerve palsy.

Compression, contusion or disruption of the popliteal artery is not so rarely caused by low energy anterior displacement of the tibia on the femur.

Limb survival may be compromised.

Mandatory emergency restoration of blood supply would possibly modify immediate and subsequent surgical strategies.

There has not however been any study exclusively devoted to double joint and vascular involvement.

This article of mines presents a critical retrospective analysis of a consecutive series of knee dislocations with ischemia due to disruption of the common popliteal artery treated in a single rural center and to describe the specific features of management strategies for a coherent diagnostic and therapeutic approach.

Klippel-Feil syndrome

Klippel-Feil syndrome occurs in a heterogeneous group of patients unified only by the presence of a congenital defect in the formation or segmentation of the cervical spine.

Numerous associated abnormalities of other organ systems (heart…)  may be present.

This heterogeneity requires comprehensive evaluation of all patients and treatment regimes that can vary from modification of activities to extensive spinal surgeries.

This also has made delineation of diagnostic and prognostic classes difficult and has complicated elucidation of the genetic etiology of the syndrome.

Furthermore, it is unclear whether Klippel-Feil syndrome is a discrete entity, or if it is one point on a spectrum of congenital spinal deformities.

Pedigree analysis has identified a human genetic locus for the disease.

Mouse models suggest members of the PAX gene family and Notch signaling pathway as possible etiologic candidates.

Only by identifying the link between the genetic etiology and the phenotypic pathoanatomy of Klippel-Feil syndrome will we be able to rationalize the heterogeneity of the syndrome.

Tenosynovitis of the flexor tendons of the hand detected by MRI: an early indicator of rheumatoid arthritis

Flexor tenosynovitis diagnosed by MRI of the hand is a strong predictor of early RA.

Combining flexor tenosynovitis on MRI with positive serum anti-CCP or positive RF is an even stronger predictor of early RA.