Faculty Bibliography

PURPOSE: Posterior shoulder dislocations are rare, and are usually the result of seizures. Anterior defects of the humeral head known as "reverse Hill-Sachs lesions" may increase the risk of recurrent dislocation and are difficult to treat. We developed a percutaneous technique for reduction of the dislocation or reduction of the anterior impaction fracture, using percutaneous balloon dilatation and cement fixation. METHODS: From 2009 to 2012, three patients aged 33, 72 and 75 years were admitted to our institution with a posterior shoulder dislocation showing an anterior "reverse Hill-Sachs" impaction fracture. One case was bilateral (four fractures). Patients were operated upon in the sitting position; the humeral head was stabilised by external fixator pins during balloon inflation. Reduction or filling of the defect was obtained in all cases. All patients were followed up and two patients (three fractures) were examined after one year by an independent observer. The clinical results were assessed using the Constant score and the RAND-36 physical components score. A computed tomography (CT) scan was obtained in all patients before and after the operation and at the latest follow-up. RESULTS: At three months postoperatively, all patients had resumed work or daily life activities with no limitation. The mean Constant score was 71 and RAND-36 score was 85.5. After one year, the mean Constant score was 73 and the RAND-36 score was 86.4 for the two patients who had sufficient follow-up. On the postoperative radiograph and CT scan, sphericity of the humeral head was restored, and the reverse Hill-Sachs impaction was filled or reduced in all cases. There was no recurrent dislocation. CONCLUSION: Based on this small series, we believe that this technique should be added to our current armamentarium for posterior shoulder dislocations showing a deep impaction fracture of the humeral head that are at risk for recurrent dislocation.

The prognosis of severe trauma patients is determined by the ability of a healthcare system to provide high intensity therapeutic treatment on the field and to transport patients as quickly as possible to the structure best suited to their condition. Direct admission to a specialized center ("trauma center") reduces the mortality of the most severe trauma at 30 days and one year. Triage in a non-specialized hospital is a major risk of loss of chance and should be avoided whenever possible. Medical dispatching plays a major role in determining patient care. The establishment of a hospital care network is an important issue that is not formalized enough in France. The initial triage of severe trauma patients must be improved to avoid taking patients to hospitals that are not equipped to take care of them. For this purpose, the MGAP score can predict severity and help decide where to transport the patient. However, it does not help predict the need for urgent resuscitation procedures. Hemodynamic management is central to the care of hemorrhagic shock and severe head trauma. Transport helicopter with a physician on board has an important role to allow direct admission to a specialized center in geographical areas that are difficult to access.

The initial management of trauma patients in a dedicated location is a crucial step in the treatment of these patients. The characteristics of this phase are such that they meet all the criteria for a professional practice patterns evaluation (PPPE or PPE): formalized protocols, clear-cut timeframes, specific roles of different stakeholders, and multidisciplinary medical and paramedical team. In addition, the expected result of the PPE approach, improved care, will have a direct impact on patient outcomes. This PPE modeled on an audit aims at evaluating the care process based on representative criteria. These criteria should include: the planned structure and organization; the protocols; the strategy and time frames for procedure implementation; the relationships between stakeholders; the results. For each criterion, differences between the expected characteristics and the observed reality are analyzed. The prospective (independent observer or video) and/or retrospective (records, register) collection of data during 20 consecutive encounters should be sufficient to identify dysfunctions and provide guidance on the changes that need to be implemented. The proposed data collection form includes 15 items representative of the five defined criteria. These items often describe departmental choice. The pursuit of quality is defined first in terms of medical and paramedical results, but also in administrative and financial terms. Following the analysis produced by a representative group of actors, a multidisciplinary discussion of the results should be followed by proposals for simple changes approved by everyone. After a few months of implementation, the impact of the proposed improvement measures will be assessed by a new survey. This approach, in addition to improving the quality of care, allows better team stress management and greater work enjoyment.

Spinal anaesthesia is a safe and reliable anaesthetic modality for surgical procedures on the lower part of the body. However, because of the description of transient neurologic symptoms (TNS), most practitioners have abandoned intrathecal lidocaine. Chloroprocaine (2-chloroprocaine, CP) has been one candidate to replace lidocaine for short procedures, despite the fact that neurologic sequelae have been described following the intrathecal injection of large doses of preservative-containing CP intended for epidural use. The National Library of Medicine's Medline and the EMBASE databases were searched for the time period 1966 to April 2012. Fourteen studies of the use of intrathecal CP were analysed, including seven volunteer and seven clinical studies. Preservative-free CP appears to be a reliable local anaesthetic for short procedures. The duration of the surgical block can be adjusted by varying the dose between 30 and 60 mg. Two double-blind randomised controlled studies demonstrate decreased time to ambulation and discharge when CP is used for spinal anaesthesia when compared with other local anaesthetics. The addition of fentanyl appears to prolong the surgical block without significantly prolonging the time to discharge. There have been five possible cases of TNS following CP spinal anaesthesia in over 4000 patients, and a regressive incomplete cauda equina syndrome has been described. The short duration of spinal CP makes it a strong contender for outpatient anaesthesia. It appears to have a lower risk of TNS than lidocaine.

PURPOSE: Balloon reduction and cement fixation of displaced articular fractures of the calcaneus have been described elsewhere but support for it lacks clinical evidence. We have been performing the technique since October 2006 and describe here our clinical experience including three to five-year follow up of our first ten cases with no patient lost to follow up. METHODS: From September 2006 to September 2009, ten patients were admitted with a calcaneus fracture, six were female and four male, one case was bilateral (11 fractures). Patients were operated upon in the prone position according to the technique we have described. Reduction was obtained in all cases. Patients were discharged after an average of four days postoperatively and were allowed weight bearing after two to three months. All patients were followed up regularly and were examined by an independent observer at the latest follow up. The clinical results were assessed using the AOFAS ankle score, the Babin score and the RAND-36 physical components score. A CT scan was obtained in all patients before, after the operation and at the latest follow up. RESULTS: After a minimal follow up of 36 months (three to five years), no patient was lost to follow up and none required further surgery. The AOFAS clinical results were rated good or excellent in 81.8 % of cases (nine fractures, eight patients), and the physical component of the RAND-36 was 74.6. One patient only (one fracture) had a bad clinical result and evidence of subtalar arthritis on the CT scan and was offered a subtalar fusion; she refused. All patients had returned to their former professional activities at the same level as before the fracture except one who had retired but had resumed leisure walking. CONCLUSION: Balloon reduction and cement fixation of fresh calcaneal fractures ("balloon calcaneoplasty") appears a safe and effective procedure in a variety of calcaneal fractures with lasting and excellent clinical results. More studies are needed to further refine the indications and the limits of the procedure.

BACKGROUND: Out-of-hospital refractory cardiac arrest patients can be transported to a hospital for extracorporeal life support (ECLS), which can be either therapeutic or performed for organ donation. Early initiation is of vital importance and the main limitation when considering ECLS. This explains that all reported series of cardiac arrest patients referred for ECLS were urban ones. We report a series of rural out-of-hospital non-heart-beating patients transported by helicopter. METHODS: This observational study was performed in two rural districts in France. Data on patients with pre-hospital criteria for ECLS who were transported to the hospital by helicopter, maintained by mechanical chest compression, were recorded over a 2-year period. RESULTS: During the study period, 27 patients were referred for ECLS, of which 14 for therapeutic ECLS and 13 for organ preservation. The median transport distance was 37 km (25th and 75th percentiles: 31-58; range 25 to 94 km). Among the therapeutic ECLS patients, one survived to discharge from the hospital. Liver and kidneys were retrieved in another patient after brain death was ascertained. In the 13 patients referred for organ donation, four were excluded for medical reasons; 18 kidneys were retrieved in nine patients, of which six kidneys were successfully transplanted. CONCLUSION: In this preliminary study, we report the feasibility and the interest of helicopter transport of refractory cardiac arrest patients maintained by mechanical chest compression. Patients with refractory cardiac arrest occurring in rural areas, even at distance from a referral centre, can be candidates for ECLS.