MRI of brachial plexus using diffusion tensor imaging: a pilot study for the use of resolve sequence surgical and radiologic anatomy

BACKGROUND

Clinical exam is the goldstandard for surgical indication. ENMG and conventional MRI are insufficient to understand the highly variable clinical presentation of brachial plexus (BP) lesions. DTI is based on motion of water molecules and can explore nerve function.

PURPOSE

This pilot study of healthy subjects aimed to develop RESOLVE sequence for BP exploration using diffusion MRI. The main objective was to provide complete precise information from DTI cartography associated with anatomical data.

METHODS

Six healthy volunteers were scanned using 3T PRISMA scanner with anatomic 3D STIR SPACE and RESOLVE diffusion sequences. Diffusion parametric maps of fractional anisotropy (FA) were extracted from RESOLVE acquisitions. A reproducible method for roots volumes and angles measurements was created using 3DSlicer. ROI were segmented on Mean B0 sequences. FA measurements were obtained with ROI on Mean B0 sequences.

RESULTS

RESOLVE sequence was adapted to the BP. Mean FA was 0.30. Angles measurements on 3D STIR SPACE sequences showed increasing values from proximal to distal roots with an 0.6 ICC. Volume measurements on anatomic sequences varied widely from one root to another but did not show any significant difference on laterality.

CONCLUSIONS

A new and reproducible method for BP exploration was developed, using MRI RESOLVE DTI sequences. Complete mapping was obtained but a low resolution of track density imaging did not allow to exploit distal nerves. Deterministic tractography principal limit was the lack of resolution. Extraction of diffusion, volumetric and angular parameters of the plexus roots, and scripts creation for image processing was adapted to the healthy BP.

Forearm reconstruction by induced-membrane technique after sarcoma resection in children: technique and functional outcome in three cases

Forearm sarcoma is rare in children. Here, we report three cases. One child presented undifferentiated soft-tissue sarcoma involving the ulna, another had Ewing's sarcoma of the ulna, and the third had Ewing's sarcoma of the proximal radius. In the first case, there were episodes of iterative aseptic nonunion, treated surgically. At last follow-up (respectively 11, 9 and 8 years postoperatively), the mean Musculoskeletal Tumor Society (MSTS) score was 80%, 90% and 77% respectively, and all cases were in remission. The induced membrane technique to reconstruct bone defect after sarcoma resection in children is a possible limb-salvage strategy.

Is daily walking distance affected in adolescent idiopathic scoliosis? An original prospective study using the pedometer on smartphones

BACKGROUND DATA

Little is known about daily walking distance levels, which accounts for approximately 80% of overall physical activity per day, in adolescents with idiopathic scoliosis (AIS).

OBJECTIVE

The aim of this study was to assess the level of walking distance in AIS treated by bracing or not, comparing this activity with that of a control group. We used an original method based on smartphone pedometers for studying walking distance in everyday life.

METHODS

Nineteen AIS patients, aged 14.1 (13-17) years, and 25 asymptomatic patients, aged 12.9 (12-14) years were included prospectively. The 19 AIS cases comprised 9 untreated individuals and 10 with ongoing night brace treatment. The mean walking distance per day as estimated by the pedometer application on smartphones for 2 months was assessed. Weekly sports activities (hours per week) were also reported.

RESULTS

During the first month, the mean walking distance was 2.58±0.65 km/day for control patients, 2.31±1.38 km/day for untreated AIS, and 3.65±0.72 km/day for AIS patients treated with a night brace. During the second month, the mean walking distance was 2.60±0.73 km/day for control patients, 2.40±1.41 km/day for untreated AIS, and 3.70±0.72 km/day for AIS patients treated with a night brace. Statistical analysis between groups showed a statistically significant difference with a higher level of daily walking distance in adolescents treated with a night brace compared with other groups.

CONCLUSION

The pedometer on smartphones is a cost-effective and friendly tool to assess adolescents' level of walking distance. Our results indicate no restriction in terms of daily walking distance between adolescents without scoliosis and those with idiopathic scoliosis.

LEVEL OF EVIDENCE

Level II.

Neuromuscular diseases: Diagnosis and management

Neuromuscular diseases (NMDs) affect the peripheral nervous system, which includes the motor neurons and sensory neurons; the muscle itself; or the neuromuscular junction. Thus, the term NMDs encompasses a vast array of different syndromes. Some of these syndromes are of direct relevance to paediatric orthopaedic surgeons, either because the presenting manifestation is a functional sign (e.g., toe-walking) or deformity (e.g., pes cavus or scoliosis) suggesting a need for orthopaedic attention or because orthopaedic abnormalities requiring treatment develop during the course of a known NMD. The main NMDs relevant to the orthopaedic surgeon are infantile spinal muscular atrophy (a motor neuron disease), peripheral neuropathies (chiefly, Charcot-Marie-Tooth disease), congenital muscular dystrophies, progressive muscular dystrophies, and Steinert myotonic dystrophy (or myotonic dystrophy type 1). Muscle weakness is a symptom shared by all these conditions. The paediatric orthopaedic surgeon must be familiar, not only with the musculoskeletal system, but also with many other domains (particularly respiratory and cardiac function and nutrition) that may interfere with the treatment and require preoperative management. Good knowledge of the natural history of each NMD is essential to ensure optimal timing of the therapeutic interventions, which must be performed under the best possible conditions in these usually frail patients. Timing is particularly crucial for the treatment of spinal deformities due to paraspinal muscle hypotonia during growth: depending on the disease and natural history, the treatment may involve non-operative methods or growing rods, followed by spinal fusion. A multidisciplinary approach is always required. Finally, the survival gains achieved in recent years increasingly require attention to preparing for adult life, to orthopaedic problems requiring treatment before the patient leaves the paediatric environment, and to the transition towards the adult healthcare system.

Allograft integration in a rabbit transgenic model for anterior cruciate ligament reconstruction

BACKGROUND

Tissue engineering strategies include both cell-based and cell homing therapies. Ligamentous tissues are highly specialized and constitute vital components of the musculoskeletal system. Their damage causes significant morbidity and loss in function.

HYPOTHESIS

The aim of this study is to analyze tendinous graft integration, cell repopulation and ligamentization by using GFP+/- allografts in GFP+/- transgenic New Zealand white (NZW) rabbits.

MATERIAL AND METHODS

Graft implantation was designed to closely mimic anterior cruciate ligament (ACL) repair surgery. Allografts were implanted in 8 NZW rabbits and assessed at 5 days, 3 weeks and 6 weeks through: (1) arthroCT imaging, (2) morphological analysis of the transplanted allograft, (3) histological analysis, (4) collagen type I immunochemistry, and (5) GFP cell tracking. Collagen remodeling was appreciated at 3 and 6 weeks.

RESULTS

Graft repopulation with host cells, chondrocyte-like cells at the tendon-bone interface and graft corticalization in the bone tunnels were noticed at 3 weeks. By contrast we noticed a central necrosis aspect in the allografts intra-articularly at 6 weeks with a cell migration towards the graft edge near the synovium.

DISCUSSION

Our study has served to gain a better understanding of tendinous allograft bone integration, ligamentization and allograft repopulation. We believe that both cell-based therapies and cell homing therapies are beneficial in ligament tissue engineering. Future studies may elucidate whether cell repopulation occurs with pre-differentiated or progenitor cells. We believe that both cell-based therapies and cell homing therapies are beneficial in ligament tissue engineering.

LEVEL OF EVIDENCE

Level V (animal study).

Isolated C5-C6 avulsion in obstetric brachial plexus palsy treated by ipsilateral C7 neurotization to the upper trunk: outcomes at a mean follow-up of 9 years

Cervical root avulsions are the worst pattern of injury in obstetrical brachial plexus injury (OBPI). The prognosis is poor and the treatment is mainly surgical with extraplexual neurotizations or muscle transfers. We present the outcomes of a technique performed in our institution to treat C5-C6 avulsion in obstetrical brachial plexus injury. This technique consists of a total ipsilateral C7 neurotization to the upper trunk. Ten babies with isolated C5-C6 root avulsion were operated on; we were able to review nine of them at over 12 months follow-up. The shoulder and the elbow function were assessed, as well as the Mallet Score. The mean follow-up was 9.2 years (SD 5.7). After a follow-up of 6 years, elbow flexion was restored with a range of motion ⩾130° and a motor function ⩾M3 in all patients. The average Mallet score was 18.1 (SD 1.2). This approach appears to be a viable alternative to extraplexual neurotizations for the treatment of C5-C6 nerve root avulsion.

[Congenital foot abnormalities]

The foot may be the site of birth defects. These abnormalities are sometimes suspected prenatally. Final diagnosis depends on clinical examination at birth. These deformations can be simple malpositions: metatarsus adductus, talipes calcaneovalgus and pes supinatus. The prognosis is excellent spontaneously or with a simple orthopedic treatment. Surgery remains outstanding. The use of a pediatric orthopedist will be considered if malposition does not relax after several weeks. Malformations (clubfoot, vertical talus and skew foot) require specialized care early. Clubfoot is characterized by an equine and varus hindfoot, an adducted and supine forefoot, not reducible. Vertical talus combines equine hindfoot and dorsiflexion of the forefoot, which is performed in the midfoot instead of the ankle. Skew foot is suspected when a metatarsus adductus is resistant to conservative treatment. Early treatment is primarily orthopedic at birth. Surgical treatment begins to be considered after walking age. Keep in mind that an abnormality of the foot may be associated with other conditions: malposition with congenital hip, malformations with syndromes, neurological and genetic abnormalities.

Proximal ulnar osteotomy in the treatment of neglected childhood Monteggia lesion

INTRODUCTION

The aim of our study was to analyze medium and long-term results of proximal ulnar osteotomy with and without ligament injury in neglected Monteggia injury in children.

MATERIAL AND METHODS

This retrospective, multicenter study included 28 patients. Clinical criteria concerned the range of motion, pain and MEPI score, and radiologic criteria comprised of Storen line, head-neck ratio, radial neck angle, and signs of osteoarthritic remodeling.

RESULTS

Twenty-eight patients were reviewed, at a mean 6 years' follow-up (range, 2-34y). Sixteen had proximal ulnar osteotomy without ligament reconstruction, and 12 had associated ligamentoplasty. Both groups showed significant clinical and radiological improvement, with no significant difference. Patients operated within less than 1 year had better clinical and radiographic results. There was no correlation between age at surgery and quality of results. The 5 patients who underwent condyloradial pinning showed early recurrence of dislocation and osteoarthritic remodeling. The three cases of Bado type-3 lesion had early recurrence of dislocation.

DISCUSSION

Proximal ulnar osteotomy gives good long-term results in Bado type-1 lesions, regardless of age, if performed before 1 year, in the absence of osteoarthritic remodeling. Associated ligamentoplasty does not seem to be useful.

LEVEL OF EVIDENCE

IV (retrospective).

Postoperative perceived health status in adolescent following idiopathic scoliosis surgical treatment: results using the adapted French version of Scoliosis Research Society Outcomes questionnaire (SRS-22)

PURPOSE

Assessing functional outcome from patient-based outcomes questionnaires are essential to the evaluation of adolescent idiopathic scoliosis surgical treatment

METHODS

At the minimum follow-up of 2 years, 45 operated on adolescent idiopathic scoliosis patients were mailed the French version of the Scoliosis Research Society Outcome Instrument (SRS-22) questionnaires containing items on pain, activities of daily living, and satisfaction.

RESULTS

Mean values of the SRS-22 domains were 3,66 for the Pain domain, 3,85 for the Self-perceived image domain, 4,32 for the Function domain, 3,52 for the Mental health domain and 4,12 for the Global satisfaction with management domain. Mean value of the global SRS-22 score was 3,88. We showed no differences in functional SRS-22 health status in patients according to the type of curve (Lenke classification). We showed statistically significant correlations between the gain of Cobb angle and Patients self-image and function domain scores. There was a statistically significant correlation between preoperative Cobb angle and patient satisfaction with management.

CONCLUSIONS

Even if Function and Self-image scores in our patients are close to control group values, indicating good short to mid-term outcome of surgical treatment, scores for pain and mental health status were significantly lower in patients than controls. Long-term follow-up studies conducted by multiple surgeons over successive generations are mandatory to assess clinical significance of these differences.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

Neuromuscular scoliosis

Scoliosis is a common deformity in many types of neuromuscular disease. Severe spinal curvature can cause difficulty in sitting. Conservative and surgical treatment of neuromuscular scoliosis differs from idiopathic scoliosis, being more complex and with a higher complications rate. Non-surgical measures rarely fully control progressive scoliosis, but aim to prevent spinal deformities secondary to muscular hypotonia or contracture. Twenty-four hour bracing should be adjusted throughout growth, and may induce functional impairment and loss of independence. Corrective surgery requires multidisciplinary management and perioperative screening. Pelvic obliquity is commonly associated with neuromuscular scoliosis, making sitting difficult: correction needs to be considered during surgical planning. The goal of surgical correction is to obtain and maintain a well-balanced spine above a well-positioned pelvis. Preoperative multidisciplinary assessment enables potential problems of terrain to be anticipated. Respiratory function investigation will guide possible non-invasive perioperative ventilation. Nutritional and psychosocial assessment should also be incorporated in this preparation, as should overall postoperative care. Implementing this overall strategic planning can achieve a good surgical and functional result in the vast majority of cases.

[Chronic pericarditis: CT and MR imaging features]

A diagnosis of constrictive pericarditis is suggested by the presence of pericardial thickening (>=4 mm in thickness) and abnormal motion of the interventricular septum. Additional findings have been reported: tubular appearance of the right or left ventricles, dilatation of the vena cava, atrial dilatation or abnormal diastolic expansion of one or both ventricles. In patients with suspected chronic pericarditis, CT can more easily demonstrate the presence of pericardial calcifications compared to US and MRI, as well as detect the presence of mediastinal adenopathy and lung lesions, suggesting tuberculosis. Septal motion analysis should be performed during protodiastole and systole using a cine technique with both CT and MR.

[Imaging in the diagnosis and the staging of gallbladder tumors]

Most of gallbladder tumors are benign. Adenoma, cholesterol polyps, or adenomyomatosis are most frequently typical on ultrasonographic images. All symptomatic lesions must be considered as indications for surgery. It may be difficult to identify precancerous or malignant lesion. Polyps over 1cm are indication for preventive cholecystectomy. In case of suspicious polyp or suspicious wall thickening, endoscopic ultrasonography can be helpful to evaluate local tumoral spread and eliminate differential diagnosis. Unfortunately, diagnosis of gallbladder cancer is often late, when surgical resection can't be curative. Computed tomography and magnetic resonance imaging examinations are then useful for local and metastatic staging.

A novel radiofrequency thermocoagulation method for treatment of lower back pain: thermal conduction after instillation of saline solution into the nucleus pulposus--preliminary results

BACKGROUND

Radiofrequency heating of the intervertebral disc has been proposed for the treatment of chronic low back pain using two methods: a flexible needle inserted into the annulus fibrosus achieving a full 360 degrees penetration, or a rigid needle inserted into the nucleus pulposus. The first technique is effective on pain, but the clinical benefit of the second is uncertain.

PURPOSE

To evaluate a technique for radiofrequency heating of the lumbar intervertebral disc by a needle placed into the nucleus pulposus.

MATERIAL AND METHODS

The method was tested in 17 patients according to the criteria used in previous intradiscal radiofrequency studies. Before and after treatment, disability was assessed by the Oswestry disability score. A pain reduction of at least 50% was considered a success.

RESULTS

Fifteen patients were responders at 1 month (88%), nine at 3 months (53%), and 12 at 6 months (70.6%). No complications were observed.

CONCLUSION

A new method of providing discal radiofrequency treatment for lower back pain had a substantial clinical benefit in 71% of the observed patients. A prospective study comparing this new method with placebo should be conducted to confirm these initial results.

Spinal trauma with a complete anterior vertebral body dislocation: a report of three cases

STUDY DESIGN

Retrospective review of three cases.

OBJECTIVES

Severe trauma can be responsible for a complete spinal anterior dislocation with a 100% anterior slip of the vertebral body. Three cases of this uncommon lesion are reported.

SETTING

France.

METHODS

The data of three cases of complete spinal anterior dislocation with a 100% anterior slip of the vertebral body were retrospectively reviewed.

RESULTS

In all the cases, the vertebral dislocation was responsible for a severe neurological deficit and all patients had severe associated lesions. The diagnosis was made on plain radiographs. In one case of a multilevel injury, an extensive instrumented spinal fusion was necessary. In spite of the severe injury, two neurological deficits improved thanks to pedicular fractures, which widen the canal.

CONCLUSION

The therapeutic goal is to achieve emergent vertebral alignment, neurological decompression and solid spinal fusion. A posterior facilitates this. Reduction of vertebral dislocation can be difficult to achieve and it is therefore mandatory to perform complete arthrectomy of the injured levels before reduction. Especially in young patients, severe disc lesions secondary to the wide vertebral displacement make it necessary to perform circumferential fusion.

[Sagittal balance of the spine and degenerative spondylolisthesis]

PURPOSE OF THE STUDY

Several reports have examined the pathophysiology of degenerative spondylolisthesis. Very little work has however been devoted to the influence of spinal balance in the sagittal plane in its pathogenesis. The purpose of this work was to present a descriptive analysis of pelvic and spinal sagittal balance in a cohort of seventy patients treated for degenerative spondylolisthesis and to compare findings with those established in a population of 250 volunteers. The goal was to deduct pathophysiological hypotheses and identify therapeutic implications.

MATERIAL AND METHODS

Seventy patients were included in this study. The following variables were noted: pelvic incidence and version, sacral slope, lumbar lordosis, thoracic kyphosis, T9 sagittal tilt and S1-S2 angle. These variables were measured on digitalized lateral views of the spine using a dedicated software (SpineView). Univariate analysis of the values obtained was performed to identify the variable distributions. Multivariate analysis was applied to study the relationships between these variables and to better define perturbations of spinal balance in the anteroposterior plane. The findings were compared with those obtained in a control population.

RESULTS

One of the essential characteristics of the cohort of patients with degenerative spondylolisthesis was the presence of an exaggerated pelvic incidence (62.6 degrees versus 54.7 degrees in the control population). The most significant determinants of T9 sagittal tilt (which reflects sagittal balance) were: pelvic version, pelvic incidence, lumbar lordosis, and L4-S1 local lordosis. One-third of our patients presented posterior tilt due to exaggerated thoracic kyphosis. The high pelvic incidence, via hyperlordosis and increased pelvic version, could be one of the factors favoring degenerative disease of the spinal unit.

CONCLUSIONS

This work enabled us to better describe sagittal balance in patients with degenerative spondylolisthesis and to propose hypotheses concerning the underlying mechanism of progressive degeneration. We emphasize the diversity of spinal balance in these patients and the different therapeutic implications.

Fractures de Tillaux de l’adolescent

PURPOSE OF THE STUDY

Tillaux fractures in adolescents correspond to Salter and Harris type III fractures involving the anterolateral portion of the tibial epiphysis. These are intra-articular fractures. The objective was to determine the circumstances of these fractures, the radiological signs, and the therapeutic modalities as well as the long-term clinical and radiological outcome.

MATERIAL AND METHODS

We reviewed 19 Tillaux fractures. Ten patients underwent surgical treatment and nine orthopedic treatment following importance of displacement.

RESULTS

At mean follow-up of 33.8 months, results were rated good in 17 on 19 cases.

DISCUSSION

This fracture is often observed in teenagers victims of trauma with external rotation of the foot. Closure of distal growth cartilage of the tibia occurs medially to laterally, the anterolateral portion remaining open longer. Forced external rotation of the anterior tibiofibular ligament pulls off an anterolateral fragment of the distal tibial epiphysis. Surgical treatment is indicated for fractures with a displacement of more than 2 mm or a vertical displacement to achieve open reduction and screw fixation. Orthopedic treatment is used for non-displaced fractures.

CONCLUSION

The prognosis of Tillaux fractures is good as was observed in our series and in series reported in the literature.

Multiple lumbar plexus neurotizations of the ninth, tenth, and eleventh intercostal nerves

The topographic anatomy of the lower intercostal nerves is less known than the upper ones except for the twelfth intercostal nerve. It is possible to use the lower intercostal nerves to carry out a neurotization of the lumbar roots. We studied the anatomy of the ninth, tenth, and eleventh intercostal nerves in order to specify the data of descriptive and topographic anatomy allowing to carry out their harvesting under good conditions. Ninth, tenth, and eleventh intercostal nerves of 50 cadavers were dissected. The proximal part of the nerve in the posterior intercostal space was exposed through a posterior approach. The lateral intercostal space was exposed through a lateral approach, under the latissimus dorsi, which made it possible to harvest the intercostals nerve. The proximal course of the nerve in posterior intercostals space was the same in all the cases. The nerve moves obliquely towards the outside to reach the lower border of the rib. The exit of posterior intercostal space is a fibrous strait that marks the entry of a channel between two muscular layers. We describe an aponevrotic channel in which the nerve and the vessels are, immediately at the lower border of the cranial rib. The mean total length of intercostal nerve harvested by our technique was 17.96 cm for the ninth intercostal nerve, 17.14 cm for the tenth intercostal nerve, and 15.94 cm for the eleventh intercostal nerve. The bifurcation of the intercostal nerve in a deep branch and the ramus cutaneus lateralis was found in the majority of the cases, from 9.5 to 21 cm of the emergence of the intercostal nerve in posterior intercostal space. This anatomical study of the ninth, tenth, and eleventh intercostal nerves in posterior intercostal space and lateral intercostal space appears to us to allow the realization of a reliable surgical harvesting.

[Surgical treatment of lumbosacral spondylolisthesis with major displacement in children and adolescents: a continuous series of 20 patients with mean 5-year follow-up]

PURPOSE OF THE STUDY

This retrospective analysis involved a continuous series of twenty cases of lumbosacral spondylolisthesis with major displacement treated before maturity. We compared our experience using a non-instrumented lumbosacral fusion technique with the results of other techniques proposed in the literature.

MATERIAL AND METHODS

We reviewed the cases of twenty children and adolescents who underwent surgery in our unit. For each case, we recorded the clinical history and course to last follow-up. X-rays were studied and manual measurements taken of the different parameters used to analyze the spine. Data were recorded in a database for statistical analysis. Sixteen of the twenty cases showed spinal deformation causing lumbalgia, generally associated with radiculalgia. Mean age at surgical treatment was 13 years 3 months, range 7 years 2 months to 17 years 6 months. All of the children has Meyerding stage 3 or 4 displacement associated with lumbosacral kyphosis. Surgical treatment followed a period of progressive reduction by traction and suspension in lordosis using a hammock. All twenty patients underwent posterolateral arthordesis using a cancellous graft between L4 and the sacrum. The fusion was performed after fashioning a thoraco-lumbo-pelvic cast including both thighs in the position of reduction. A complementary time for anterior arthodesis was needed for eight patients.

RESULTS

The postoperative period was uneventful in twelve patients. Two children developed intestinal obstruction with a peritoneal bridle. Three children had an L5 radicular deficit and three sphincter disorders. All neurological disorders resolved in a few months. At mean postoperative follow-up of 5 years 3 months, the arthrodesis appeared to be fused in 19/20 cases. Only one patient presented a lucent line in the zone of the bone graft suggesting possible fibrous nonunion. Eighteen patients were symptom free and led a normal life. Two patients complained of moderately bothersome lower back pain.

DISCUSSION

Many of the children in our series had major lumbosacral dysplasia with a verticalized sacrum, aggravating the lumbosacral kyphosis. This led to an increased pelvic tilt and decreased sacral slope. Progressive preoperative reduction of the lumbosacral kyphosis allowed conducting the lumbosacral fusion under favorable conditions. We did not open the spinal canal and avoided the mid line in order to protect as much as possible posterior spinal stability and preserve all the bone surfaces receiving the posterolateral graft. We reserved indications for complementary anterior lumbosacral arthrodesis to the most exaggerated cases of lumbosacral kyphosis. The therapeutic program is long due to the progressive preoperative reduction and the strict period of immobilization after surgery. In our experience, this approach allows quality lumbosacral fusion with good correction of the lumbosacral kyphosis. Neurological complications remain frequent and can occur during even slow progressive reduction.

Late spinal dislocation after treatment of spinal arteriovenous malformation

Neuropathic arthropathy of the spine is a destructive condition of the spine which is secondary to a loss of the protective proprioceptive reflexes. In the majority of cases, it occurs in patients who have suffered from traumatic medullary lesions and is responsible for destruction of the vertebral bodies and considerable spinal deformity. We report a case of neurogenic lumbar arthropathy in a patient with a spinal arteriovenous malformation. This vascular lesion caused considerable disturbances of proprioception. The course was favorable with regard to the deformity after correction and fusion by posterior approach.

The thoracoabdominal intercostal nerves: an anatomical study for their use in neurotization

The topographic anatomy of the lower intercostal nerves is less known than that of the upper ones, except for the subcostal nerve (twelfth intercostal nerve). It is possible to use the lower intercostal nerves to neurotize the lumbar roots. We studied the anatomy of the ninth, tenth and eleventh intercostal nerves in order to specify the descriptive and topographical anatomical data that will allow their harvest in good condition. The ninth, tenth and eleventh intercostal nerves of 30 cadavers were dissected. The proximal part of the nerves in the posterior intercostal space was exposed through a posterior approach. The lateral intercostal space was exposed through a lateral approach, deep to the latissimus dorsi, that made it possible to harvest the intercostal nerve. The proximal course of the nerves in the posterior intercostal space was the same in all cases. The nerves move obliquely towards the outside to reach the lower border of the rib. The exit of the posterior intercostal space is a fibrous strait, which marks the entry of a channel between two muscular layers. We describe an aponeurotic channel in which the nerve and vessels run, immediately at the lower border of the cranial rib. The mean total length of intercostal nerve harvested by our technique was 17.86 cm for the ninth intercostal nerve, 16.95 cm for the tenth and 15.75 cm for the eleventh. Bifurcation of the intercostal nerve into a deep branch and the lateral cutaneous branch was found in the majority of the cases, 9.5-21 cm from the emergence of the intercostal nerve in the posterior intercostal space. This anatomical study of the ninth, tenth and eleventh intercostal nerves in the posterior intercostal and lateral intercostal spaces appears to us to allow reliable surgical harvesting.

Fracture « tear-drop » en extension de l’axis

Tear-drop fracture of the axis is an exceptional spinal fracture which generally occurs after high-energy trauma with hyper-extension of the cervical spine. Purely anterior fracture can occur with no real impact on stability. Orthopedic treatment provides good results in this situation. If the fracture is posterior, it continues into the C2-C3 intervertebral disc and the common posterior vertebral ligament, leading to C2C3 instability and possible retrolisthesis of C2 over C3 and neurological involvement. We report a case of tear-drop fracture of C2 with C3 instability without neurological involvement. This patient underwent posterior fixation with C2C3 arthrodesis which provided good quality bone fusion without secondary displacement or clinical aggravation.

Traumatic lumbosacral dislocation: four cases and review of literature

Diagnosis, physiopathology, and treatments of four patients with traumatic lumbosacral dislocations are described. This is a rare but severe lesion of the lumbosacral junction that usually occurs in patients with multiple trauma. It often is not thought of and the diagnosis may be missed. Evidence of lumbosacral dislocation should be examined and confirmed by computed tomography scans in patients with multiple fractures of transverse lumbar processes, asymmetric lumbosacral joints on frontal images, or slipping of L5 over S1 on lateral images. Treatment consists of reduction of the dislocated and fractured parts, lumbosacral arthrodesis, a posterolateral graft, and posterior instrumentation. Instrumentation may be short, extending from L5 to S1, or long, from L4 to S1, depending on the extension of the lesion. In some cases, reduction can be done intraoperatively, when the L4-S1 instrumentation is inserted, provided L5 transpedicle screws are pulled posteriorly. It usually is preferable to explore the vertebral canal to ensure that there is no disc lesion compressing the dura before proceeding with reduction. Compression of the dura could be avoided with a preoperative magnetic resonance imaging scan on which a lesion of the L5-S1 disc is sought. Additional interbody vertebral arthrodesis should be considered when the L5-S1 disc is affected severely. This lesion should be looked for preoperatively with a magnetic resonance imaging scan and intraoperatively by exploring the canal. This can be done at the time of the posterior surgery or during a second anterior surgical procedure.

[Nocardia farcinica brain abscess: clinical and specific radiological findings and management. Report of two cases in immunononcompromised patients]

Nocardia spp. cerebral abscesses are rare and usually occur in immunocompromised patients. We report two recent cases of cerebral abscesses due to Nocardia farcinica in immunocompetent patients and review the literature about diagnosis and therapeutic issues. Outcome was good for the two patients following an early identification of the bacteria. Stereotactic biopsy was performed in one case and craniotomy with excision of the abscess in the other case. In both cases, complete identification of the bacteria could be achieved, followed by prolonged antibiotic therapy. Exposure to the germ (mainly telluric) is often difficult to suspect from the past medical history of the patient. Diagnosis is also unexpected. Despite the typically and characteristic aspect on CT and MRI, specific identification and anti-microbial sensitivity profiles are necessary to optimize treatment. In some rare cases, unusual species like Nocardia farcinica, can be resistant to numerous antibiotics requiring adjustments of medical management. Early identification of the bacteria is necessary to achieve good outcome in immunocompetents patients.

[Synovial cyst of the intercondylar fossa of the knee: three symptomatic cases and a review of the literature]

Synovial cyst of the intercondylar fossa of the knee or cyst of the "cruciate tentorium" is an uncommon finding. Most of the reports in the literature were made after the advent of magnetic resonance imaging. Most cysts are asymptomatic and discovered fortuitously. We report our experience with three cases of symptomatic cysts, describing the diagnostic and therapeutic approaches used. Clinical manifestations of symptomatic cysts are variable and non-specific. Pain is commonly observed with limitation of knee amplitudes. If their is no other suspected meniscal or osteochondral disease after clinical and MRI assessment, surgical treatment is only indicated in case of functional impairment. Medical care may be sufficient in certain cases, associating puncture and infiltration. In others surgical treatment, generally via an arthroscopic approach, is needed.

[Colonic actinomycosis. Clinical, endoscopic and histological aspects in one patient]

Colonic location of actinomycosis must be distinguished from infected colonic carcinoma and other colonic inflammatory pseudotumors. The diagnosis is often made by histological examination of the tumor. Initial treatment consists in surgery, followed by an antibiotic treatment. We report the case of a 32-year old woman with a right colonic actinomycosis.

Anatomic relations between the cephalic vein and the sensory branches of the radial nerve: How can nerve lesions during vein puncture be prevented?

The cephalic vein of the forearm is often used for IV catheters because of its ease of access for peripheral venous cannulation. But its close relation to the sensory branch of the radial nerve sometimes causes it to be damaged when the vein is cannulated. Our anatomic study conducted on 33 specimens confirmed the risk of nerve lesion. However, it is impossible to define a safe zone, because of the randomly located nerve and vein crossing zones, where the iatrogenic risk of damaging the radial nerve is maximum. We suggest that to avoid incidents, the cephalic vein should be punctured above the emergence of the sensory branch of the radial nerve, e.g., at least 12 cm above the level of the styloid process of the radius.

IMPLICATIONS

We attempted to determine the relationship between the cephalic vein and the sensory branch of the radial nerve at the wrist to help prevent lesions of the radial nerve when the cephalic vein is cannulated. We examined the anatomy of 33 postmortem specimens and suggest that puncture of the cephalic vein 12 cm or more proximal to the styloid process can prevent radial nerve lesions.

High and low lateral approaches to the popliteal artery

Using a series of 20 dissections and two anatomic transverse sections of a lower limb, the authors investigated the lateral approaches to the popliteal artery. The high lateral approach (above the knee) is not very aggressive and gives access to the retro-genicular part of the popliteal artery. After cutaneous and fascial incision, a simple gap between the vastus lateralis and biceps femoris mm. allows easy exposure of the popliteal vessels after backward retraction of the sciatic nerve. The low lateral approach to the artery (below the knee) is very aggressive for the vessels, nerves, and ligaments of the area. It involves the resection of the upper fourth of the fibula and the isolation and protection of the common peroneal nerve Nevertheless, these lateral approaches must be known and used when classic approaches (medial and posterior) are impossible.

Arterial supply of the duodenal bulb: an anatomoclinical study

An anatomic and radio-anatomic study of 15 specimens enabled us to reconsider the arterial vascularization of the duodenal bulb and to propose a new classification based on anatomoclinical criteria. The two arterial pedicles (infra- and supraduodenal) reach the bulb on its posterior aspect; each pedicle is made up of two sorts of blood currents (right and left); the posterior aspect of the bulb seems to be the most vascularized one, explaining, apart from bleeding from gastroduodenal a. erosion, the hemorrhagic character of ulcers of the posterior aspect of the bulb. The predominance of the left-hand currents explains the possible ischemia of the duodenal bulb and/or rupture of the duodenal stump after their interruption.

Anatomic and radioanatomic study of the lateral genicular arteries: application to prevention of postoperative hemarthrosis after arthroscopic lateral retinacular release

Arthroscopic lateral retinacular release can be complicated by hemarthrosis in 10 to 18% of cases. The vascular structures involved are the lateral vascular pedicles of the knee. This study examines the topography of these pedicles. Anatomic and radioanatomic studies carried out in 50 specimens defined the route of the vascular pedicles at the lateral aspect of the knee. From the measurements carried out, we noted the relative homogeneity of the routes taken by the different proximo-lateral vascular pedicles, which are highly vulnerable, and the variability of the disto-lateral arterial routes. A tracing-paper study identified two distinct routes for the disto-lateral vascular pedicle and evaluated the risk of injury to it in surgical approaches to the lateral aspect of the knee. Finally, the topographic data of the study suggest the possibility of preventive hemostasis of the proximo-lateral pedicle via a minimal approach close to the patella. Furthermore, it seems possible to avoid cutting the disto-lateral pedicle if it is localised by cutaneous trans-illumination at the beginning of the operation.

[Prevention of hemorrhagic complications in the lateral retinacular section of the patella. A study of the lateral arteries of the knee applied to the prevention of knee hemarthrosis]

PURPOSE OF THE STUDY

Arthroscopic lateral retinacular release is one of the most employed procedures for patellar chondromalacia. A literature review show a complication rate of 10 to 18 p. 100 of postoperative hemarthrosis. This work aims to study the vessels anatomy of the lateral side of the knee in order to find anatomical landmarks allowing to avoid or coagulate them.

MATERIAL AND METHODS

Thirty-three cadaver knees were dissected. Measures were made related to the lateral superior genicular artery and the lateral inferior genicular artery. A study using tracing-paper was also carried out. The main part of the work was more descriptive, studying anastomosis between the different arteries and veins location.

RESULTS

Concerning the lateral superior genicular artery, measure analysis showed that this artery was always cut in lateral patellar retinaculum. This artery never runs more than one centimeter proximally to the base of patella, which is too insufficient to escape from lateral retinacular release. We noted the possibility of locating 90 p. 100 of lateral superior genicular arteries in a minimal distance of 15 mm, in front of the lateral proximal angle of the patella. Concerning the lateral inferior genicular artery, only a few arteries, protected in the meniscal wall in its early course, can remain intact. Two thirds of these arteries are very vulnerable running across the lateral side of the knee. The study of the tracing-papers confirmed topographic study measurements. The descriptive study emphasized the number and the importance of anastomoses between these different arteries. Each artery is flanked by two large satellite veins, which also attribute a veinous origin to a possible bleeding.

DISCUSSION

The topographic study of the lateral inferior genicular vessels shows that their course varies. It seems necessary to avoid their division by performing the standard anterior lateral inferior arthroscopic portal proximally to these vessels. This can be realized at the beginning of the procedure through cutaneous transillumination. The lateral superior genicular vessels are always cut. They are nevertheless reachable through a small lateral incision of about 10 mm, distally to the lateral superior angle of the patella. 90 p. 100 at least of these arteries could be coagulated in such a way. We also emphasize the use of classical methods for the prevention of excessive venous bleeding, such as a compression dressing.

CONCLUSION

Following this anatomical study, we suggest, as a supplementary precaution, a selective hemostasis of the lateral superior genicular vessels through a small incision associated with the location of the lateral inferior genicular vessels by cutaneous transillumination.