[Complications of volar locking plates used to treat distal radius fractures]

About 10 years after volar locking plates were introduced to treat acute distal radius fractures, several papers have reported short-term complications. The aim of this paper was to report our complication rate over a 2-year period and to compare it to the literature. We found similar complication rates despite different classification systems. Because of the prospective nature of our study, we were able to demonstrate that extra-articular and/or intra-articular scores exceeding 8 points on a 12-points scale were statistically associated with more complications, irrespective of the patient's overall health and age.

[What is the role of primary or secondary hemiarthroplasty for distal radius fractures in independent elderly patients?]

The authors report their experience with wrist hemiarthroplasty for acute irreparable distal radius fractures in independent elderly patients (12 women, mean age 76years) and following failed initial treatment in the same population (5 women, mean age 75years). The first 11 cases have a mean follow-up of 30months. No complications requiring implant removal were reported. At follow-up, the mean VAS for pain was 1/10, the mean flexion-extension arc was 60°, the Lyon Wrist score was 73 % and the PRWE (Patient-Related Wrist Evaluation) was 22 points. The five patients who had secondary procedures and were reviewed at mean of 16months' follow-up did not require implant removal but there was one complete forearm rotational ankylosis with ossification. At follow-up, the mean VAS for pain was 3/10, the mean flexion-extension arc was 56°, the Lyon Wrist score was 65 % and the PRWE was 45 points. The authors believe that hemiarthroplasty is a useful salvage procedure for irreparable wrist fractures in the emergency room and after failed initial treatment in active elderly patients.

Diagnostic value of ultrasonography in elbow trauma in children: Prospective study of 34 cases

INTRODUCTION

Among the various elbow injuries in children that initially have normal radiographs, a certain number of occult fractures are only diagnosed correctly after the fact, during a follow-up visit.

PURPOSE

This study evaluated the diagnostic contribution of ultrasonography in the treatment of acute elbow injuries in children and the strategic and economic impact of using this tool alongside radiography.

MATERIALS AND METHODS

During this prospective study performed between January 1 and April 1 2014, elbow ultrasonography was performed within 6 days in all children under 15 years of age with a suspected occult fracture. The ultrasonography exam looked for lipohemarthrosis, the posterior fat pad sign and cortical disruption. If no fracture was visible on ultrasonography, a removable splint was given to the patient to relieve pain, and no radiological or clinical follow-up was scheduled. The patients were contacted again at least 15 days later to determine whether an undetected fracture was present. Lastly, we evaluated the cost of treatment with and without ultrasonography in the cases where no fracture was diagnosed.

RESULTS

In 13 cases, ultrasonography revealed lipohemarthrosis and a fat pat sign, with cortical disruption also present in 11 of these cases. In two cases, the diagnosis was made based solely on the presence of lipohemarthrosis and a fat pat sign. There were seven lateral condyle fractures, two medial epicondyle fractures and two supracondylar fractures. Among the 21 patients with normal ultrasonography, no fracture was diagnosed later on. In patients without a fracture, using ultrasonography resulted in a cost savings of €29.10 per patient versus not using it.

CONCLUSION

In our study, ultrasonography is a sensitive examination for the diagnosis of occult elbow fractures in children. When the radiography and ultrasonography are both normal, the possibility of fracture can be rule out definitively, which reduces the need for immobilization, follow-up and treatment costs. The findings of this preliminary study should be validated with a larger prospective study.

[Radiological analysis of acute distal radius fractures and clinical outcomes]

Radiological analysis of acute distal radius fractures (DRF) begins with the initial AP and lateral X-ray views. A CT scan is very often indicated. In addition to the three standard planes, 3D reconstructions are mandatory. We recommend not only AP views of the distal facets of the radius but also a complete 3D view in the surgical position. The distal ulna and carpus should also be analyzed. We describe the radiological sequence and the criteria used. These criteria are recorded in the one-page PAF chart, since they all impact the treatment choice. Clinical outcomes of DRF treatment are rarely addressed in the literature. We review the most commonly used clinical scores and describe the one that we use currently.

Escherichia coli endotoxin increases cytosolic free Ca2+ by mobilizing intracellular calcium stores in cultured endothelial cells

The effects of bacterial lipopolysaccharide (Escherichia coli 0111:B4; LPS) on cytosolic free calcium were examined in cultured bovine endothelial cells. The effect of LPS on the cellular calcium response to vasopressin was also investigated. Intracellular calcium [Ca2+]i was determined using the fluorescent probe Fluo-3/AM and confocal microscopy. LPS caused a dose-dependent increase in [Ca2+]i. The calcium response to LPS was of the same magnitude when cells were studied in the absence of extracellular calcium suggesting that the effect of LPS is due mainly to a mobilisation of intracellular calcium stores. The cellular calcium response to vasopressin was completely abolished by LPS and vice versa. These results show that LPS evokes a rapid increase in intracellular free calcium in endothelial cells. This observation may contribute to an explanation for the early initial phase of the LPS-induced vascular hyporesponsiveness.

In Vivo High-Resolution Trabecular Microstructure of Kienböck Lunate before and after Radial Shortening: A Case Report

We report a patient with stage IIIB Kienböck disease treated with radial shortening where preoperative and sequential postoperative imaging were done using in vivo high-resolution peripheral quantitative micro-computed tomography (micro-CT) scan. Sequential in vivo micro-CT scan analysis of a target zone of the Kienböck lunate of this patient demonstrated early signs of lunate remodeling (bone trabecular densification) at 5-month follow-up suggesting an ongoing healing process. These early remodeling micro-CT scan signs were confirmed at 5 years' follow-up as well.

[Shift work and night work: what effect on blood pressure?]

Shift work has become more and more common for the last thirty years. By definition, shift work disturbs the circadian rhythm and the internal clock. Even if the pathophysiological mechanisms are not well understood, a greater cardiovascular risk has been attributed to shift work. Cross-sectional and cohort studies have identified an association between shift work and an elevated blood pressure. Shift workers also present a higher incidence of hypertension and progression than day workers. Unfortunately, the heterogeneity of the studies, the multiple confounding factors, as well as the complexity to achieve a suitable comparison group make it impossible to draw firm clinical evidence. Nevertheless, this population needs a medical follow-up focused on the cardiovascular risks and blood pressure.

Primary Wrist Hemiarthroplasty for Irreparable Distal Radius Fracture in the Independent Elderly

Background Volar plating for acute distal radius fractures (DRF) in the elderly has been recommended. Some studies have suggested that open reduction with internal fixation (ORIF) in this situation results in frequent complications. Our purposes were to provide a definition of irreparable DRF in independent elderly patients and to review the results of a preliminary retrospective series of wrist hemiarthroplasty (WHA) in this patient population. Materials Between 2011 and 2014, 11 consecutive independent elderly patients (12 wrists) with irreparable intra-articular DRF were treated with primary WHA at the acute stage. A resection of the ulnar head was associated in nine wrists. A total of 11 wrists with more than 2 years of follow-up form the basis of this paper. Description of Technique The approach was dorsal longitudinal. An osteotome longitudinally entered the dorsal aspect of the fracture medial to the Lister tubercle. Two thick osteoperiosteal flaps were elevated radially and ulnarly in a fashion similar to opening a book. The distal radius articular surface was excised. The implant was pressed into the radial canal with attention to restoring distal radius length. The two osteoperiosteal flaps were brought back together and sutured so as to close, again like a book, the osseous and soft tissues around the implant. Results At mean follow-up of 30 months, average visual analog scale (VAS) pain was 1/10. Mean QuickDASH (Disabilities of the Arm, Shoulder and Hand) score was 32, and mean Patient-Rated Wrist Evaluation (PRWE) score was 24. Mean forearm rotation arc was 151°. Mean active flexion-extension arc was 60°. Mean active extension was 34°. Mean grip strength was 14 kg (64% of contralateral wrist). Mean Lyon wrist score was 73%. Bone healing around the implants was satisfactory in all but one case. Conclusions Out data suggest that treatment of irreparable DRF in the independent elderly patient with a bone-preserving WHA may be a viable option. Longer-term follow-up and comparative studies are needed to confirm the validity of this concept.

The role of arthroscopy for treatment of perilunate injuries

Background Open reduction with internal fixation (ORIF) is currently the gold standard treatment of acute perilunate injuries (PLIs). Less invasive surgery, including arthroscopic techniques, has recently emerged in the hope that results similar to those of ORIF could be obtained with less tissue disturbance. Our purpose was to review retrospectively a series of selected PLIs treated with arthroscopic assistance over the past 10 years. Materials and Methods Between 2004 and 2014, a total of 135 acute PLIs were surgically treated in our unit. A total of 27 patients were treated with arthroscopic assistance, among whom 18 were reviewed clinically and radiologically. Description of Technique After an initial closed gross reduction, radio- and midcarpal arthroscopy were performed to clean up the debris and assess the cartilaginous, bony, and ligamentous damage. In 22 cases arthroscopy was followed by either radiolunate and lunotriquetral pinning, scapholunate ligament repair, and SL joint pinning or ORIF of a scaphoid fracture through a mini-invasive dorsal approach. In the remaining six cases, fixation of the ligamentous and/or bony injuries was done using arthroscopy alone. Results Arthroscopic findings are presented as well as the clinical results in a subgroup of patients. At final follow-up, visual analog scale (VAS) pain was rated 18/100 on average (minimum 0, maximum 50). If we consider only the patients without reflex sympathetic dystrophy (RSD; n = 14), the average active wrist flexion-extension was 87° (58% of the normal contralateral side) and the average grip strength was 30 kg (71% of the normal contralateral side). Conclusions Although no statistical comparisons were made, we found that the results were similar to those of ORIF. The results of our study suggest that the use of arthroscopy to treat selected PLIs may be a reliable adjunct either alone or in combination with a dorsal mini-open approach.

[Renal aspects of sodium glucose cotransporter 2 inhibitors]

It has been known for centuries that the kidneys play a role in glucose homeostasis, yet the underlying tubular mechanisms have only been recently identified by studying patients with familial glucosuria. These insights have lead to the commercialization of a novel class of oral antidiabetic agents named gliflozines. Gliflozines induce renal glucosuria by blocking the Na-glucose cotransporter SGLT2, localized in the proximal tubule, and allow a reduction of 0.5 to 1% of glycated hemoglobin. They also diminish proximal sodium reabsorption, and reduce the glomerular hyperfiltration that is often seen in the early stages of diabetes. Preliminary data suggest that they may decrease blood pressure and have renoprotective effects. This article provides an overview of the role of kidneys in glucose homeostasis and the renal effects of SGLT2-inhibitors.

[Intermittent hemodialysis, irreplaceable in specific cases of severe poisoning]

The medical practitioner is in general well aware of the indications for hemodialysis in severe, acute or chronic renal insufficiency. Apart from the traditional indications for renal replacement therapy, there are some cases such as metfomin and ethylene glycol poisoning, lithium intoxication severe hypercalcemia and tumor lysis syndrome, in which intermittent hemodialysis is the most effective treatment, or sometimes the only effective one. Although these situations remain infrequent, it is crucial to recognize them as quickly as possible.

[What to expect from dialysis in the future?]

The number of people with end stage kidney failure is increasing worldwide, mainly due to aging of the population. Hence the need for renal replacement therapy is continually expanding. Kidney transplantation, haemodialysis and peritoneal dialysis are currently the gold standard of renal replacement therapy. These three techniques have all their specific advantages and shortcomings. Facing the high complication rate of actual techniques, an increasingly migrant population and the growing desire to respect the environment, alternatives are needed. New techniques that might improve some of these points are in development and will be reviewed in this article.

Minimally invasive repair of pectus excavatum using the Nuss technique in children and adolescents: indications, outcomes, and limitations

BACKGROUND

Pectus excavatum (PE) is a common congenital deformity. The Nuss technique for minimally invasive repair of PE involves thoracoscopy-assisted insertion of a bar or plate behind the deformity to displace the sternum anteriorly. Our objective here was to clarify the indications and limitations of the Nuss technique based on a review of 70 patients.

MATERIALS AND METHODS

A retrospective review of children managed at two centres identified 70 patients who had completed their growth and had their plate removed. Mean age was 13.8 years (range, 6-19 years). The reason for surgery was cosmetic disfigurement in 66 (95%) patients. The original Nuss technique was used in 63 patients, whereas 7 patients required an additional sub-xiphoid approach. Time to implant removal ranged from 8 months to 3 years.

RESULTS

The cosmetic outcome was considered satisfactory by the patients in 64 (91%) cases and by the surgeon in 60 (85.7%) cases. Major complications requiring further surgery occurred in 6 (8.5%) patients and consisted of haemothorax (n=2), chest wall sepsis (n=2, including 1 after implant removal), allergy (n=1), and implant displacement (n=1). Early or delayed minor complications occurred in 46 (65%) patients and resolved either spontaneously or after non-surgical therapy.

DISCUSSION

The minimal scarring and reliably good outcomes support the widespread use of the Nuss technique in children and adolescents. Our complication rates (minor, 65%; and major, 8.5%) are consistent with previous publications. In our opinion, contra-indications to thoracoscopic PE correction consist of a history of cardio-thoracic surgery and the finding by computed tomography of a sternum-to-spine distance of less than 5 cm or of sternum rotation greater than 35°. In these situations, we recommend a sub- and retro-xiphoid approach to guide implant insertion or a classic sterno-chondroplasty procedure.

LEVEL OF EVIDENCE

Level IV, retrospective descriptive cohort study.