Search

The approach to the sciatic plexus and lateral part of the sacrum is difficult. A subperitoneal anterolateral approach can be extended by sectioning the iliac bone above the acetabulum and lowering it toward the external part of the iliac wing and buttock. This transiliac anterolateral approach exposes the lumbosacral trunk, first sacral foramina and sciatic plexus to the origin of the sciatic trunk. Exposure can be extended upward by subperitoneal lumbotomy, downward by opening the ischiorectal fossa, or outward by trochanterotomy. This approach was used 18 times by one of the authors (FHD) for resection of 13 malignant tumors and 5 plexus releases. Procedure time was 3-6hours, with 500-4,000ml blood loss. The approach systematically enabled surgical objectives to be met. There was 1 septic complication that healed after debridement.

Resume L’abord du plexus sciatique et de la partie laterale du sacrum est difficile. Une voie anterolaterale sous-peritoneale peut etre agrandie par la section de l’os coxal au-dessus de l’acetabulum et l’abaissement vers le dehors de l’aile iliaque et de la fesse. Cet abord trans-iliaque antero-lateral permet d’exposer le tronc lombo-sacre, les premiers foramens sacres et le plexus sciatique jusqu’a la constitution du tronc sciatique. L’exposition peut etre agrandie en haut par une lombotomie sous-peritoneale, en bas par l’ouverture de l’espace ischio-rectal ou en dehors par une trochanterotomie. Cette voie a ete effectuee 18 fois par un des auteurs (FHD) pour la resection de tumeurs malignes (13 cas) ou la liberation du plexus (5 cas). Les interventions ont dure de 3 a 6 h, avec des pertes sanguines totales de 500 a 4000 ml. Cet abord a permis d’atteindre constamment les objectifs chirurgicaux. Il y a eu une complication septique.

Resume Introduction Parmi les multiples voies d’abord d’osteosynthese des fractures de l’acetabulum, la voie ilio-femorale elargie est moins utilisee en raison de son caractere invasif, bien qu’elle permette une exposition plus large permettant le controle de toutes les composantes des fractures complexes. Elle est actuellement moins utilisee bien que son caractere invasif ne soit pas confirme et ses resultats a long terme ne sont pas connus. Aussi nous avons mene une etude retrospective destinee a : (1) evaluer les resultats fonctionnels a long terme, (2) preciser la morbidite de cette voie d’abord. Hypothese La voie ilio-femorale elargie permet une reduction exacte et des resultats favorables a long terme. Materiel et methodes Quinze patients ont ete operes entre 1992 et 1997 d’une fracture complexe de l’acetabulum (3 transversales simples, 4 transversales + parois posterieures, 4 colonnes anterieures + hemi-transversales posterieures, une fracture en T et une fracture bi-colonne) par cette technique et par un operateur unique. Une luxation posterieure de la hanche etait retrouvee dans 4 cas et une protrusion intra-pelvienne dans 8 cas. Deux patients ont ete exclus du fait d’elements de suivi insuffisants, laissant 13 patients en etude. La morbidite chirurgicale etait evaluee par la duree operatoire, le nombre de culots globulaires transfuses, la survenue d’une lesion iatrogene ou de complication postoperatoire, la duree de la reeducation, la duree d’hospitalisation. L’evaluation fonctionnelle a distance etait realisee par l’indice WOMAC et le score de Harris, l’evaluation radiologique de l’arthrose par le score de Kellgren et celle des ossifications selon Brooker. Resultats La reduction fracturaire etait toujours anatomique, aucune complication per- ou postoperatoire n’a ete retrouvee, le nombre median de culots globulaires transfuses etait de 5 [3–10], le temps operatoire median etait de 4 heures [3–6]. La duree d’hospitalisation mediane etait de 6 semaines [6–8] (en raison d’une traction avec mobilisation precoce postoperatoire systematiquement appliquee), la reprise de l’appui etait possible a 8 semaines [8–12]. Au recul median de 22 ans [20–24], le score de Harris median etait de 83,5 points [63–92] et l’indice WOMAC median de 24,5 points [1–52]. Tous presentaient des ossifications heterotopiques Brooker 1 ou 2 ainsi qu’une coxarthrose moderee, deux patients ont ete repris pour arthroplastie (respectivement apres 1 et 11 ans de recul). Discussion La voie ilio-femorale elargie permet une reduction anatomique des fractures de l’acetabulum. Elle donne de tres bons resultats a long terme et sa morbidite n’est pas excessive. Niveau de preuve Niveau IV : etude retrospective sans groupe temoins.

Introduction Among the various options for internal fixation of acetabular fractures, the enlarged iliofemoral approach is less often used, being more invasive, although providing greater exposure enabling control of all components in complex fractures. Even so, the impact of its invasiveness has not been confirmed, and long-term results are not known. We therefore performed a retrospective study, aiming: to assess long-term functional outcome, and; to assess associated morbidity. Hypothesis The enlarged iliofemoral approach allows precise reduction, with favorable long-term outcome. Material and methods Between 1992 and 1997, 15 patients were operated on for complex acetabular fracture by a single surgeon using an enlarged iliofemoral approach. Two patients were excluded due to lack of follow-up data, leaving 13 patients for analysis: 3 simple transverse fractures, 4 transverse + posterior wall fractures, 4 anterior column + posterior hemi-transverse fractures, one T-shaped fracture and one 2-column fracture. There were 4 cases of posterior dislocation of the hip, and 8 of intrapelvic protrusion. Surgical morbidity was assessed in terms of operative time, number of packed red blood cell transfusions, iatrogenic lesions or postoperative complications, rehabilitation time, and hospital stay. Functional assessment at follow-up used the WOMAC index and Harris score; radiologic assessment used the Kellgren–Lawrence score for osteoarthritis and Brooker score for ossification. Results Reduction was in all cases anatomic. There were no intra- or post-operative complications. Median number of packed red blood cell transfusions was 5 [range, 3–10]. Median operative time was 4 hours [3–6]. Median hospital stay was 6 weeks [6–8], to allow systematic traction with early postoperative mobilization. Weight–bearing was resumed at a median 8 weeks [8–12]. At a median 22 years’ follow-up [20–24], median Harris score was 83.5 [63–92] and median WOMAC index 24.5 [1–52]. All patients showed Brooker 1 or 2 ectopic ossification and moderate osteoarthritis. Two underwent subsequent arthroplasty (at 1 and 11 years after the index procedure). Discussion The enlarged iliofemoral approach allowed anatomic reduction of acetabular fracture. It provided very good long-term results, without excessive morbidity. Level of evidence IV, retrospective non-controlled study.

In France, "article critique" became a particular teaching method in the second part of the medical curriculum. It approaches a reading exercise of scientific medical papers similar to that of journal club. It could be compared to reviewing a paper as performed by reviewers of a scientific journal. We studied the relevancy of that teaching method for the youngest medical students. Our questions were about the understanding and the analyzing ability of a scientific paper while students have just learned basic medical sciences as anatomy. We have included 54 "article critique" written by voluntary students in second and third years of medical cursus. All of the IMRaD structure items (introduction, materials and methods, results and discussion) were analyzed using a qualitative scale for understanding as for analyzing ability. For understanding, 89-96% was good or fair and for the analyzing ability, 93-100% was good or fair. The anatomical papers were better understood than therapeutic or paraclinical studies, but without statistical difference, except for the introduction chapter. Results for analyzing ability were various according to the subject of the papers. This teaching method could be compared to a self-learning method, but also to a problem-based learning method. For the youngest students, the lack of medical knowledge aroused the curiosity. Their enthusiasm to learn new medical subjects remained full. The authors would insist on the requirement of rigorous lessons about evidence-based medicine and IMRaD structure and on a necessary companionship of the students by the teachers.

The middle third of the clavicle is commonly involved in any injury and account for 5-10% of all fractures in adults. Although non-unions are rare, their treatment has not been well defined yet. This report describes the arterial supply of the clavicle to clarify the pathological mechanism and the surgical procedure of non-unions. This study was based on delineation of the thoraco-acromial and suprascapular arteries with colored latex on 17 specimens (ten cadavers). Observations were made after macroscopic dissection and maceration. The main blood supply to the middle third of the clavicle was the periosteal. This supply came from the two branches of the thoraco-acromial trunk that penetrated the pectoralis major muscle and the deltoid muscle. In 13 cases, these two periosteal branches were anastomosed between these two muscle attachments. Periosteal vascularization was always seen on the superior surface and the anterior border of the bone, but never on the inferior surface or the posterior border. The suprascapular artery contributed to supply the middle third of the clavicle by several periosteal branches and also by an independent branch. This branch was born proximally near the internal, middle thirds union and passed along the posterior face of the subclavius muscle and pierced the bone through the nutria foramina located near the external, middle thirds union. Nevertheless, intraosseous arteries were noted only in four cases. In these cases, they were never more than 2cm long. Our results showed that the periosteal blood supply located between the muscles insertions and the arterial supply from the suprascapular artery could be twice compromised in case of important displacement or severe fracture. If treatments of clavicular fractures or non-unions cannot preserve the periosteal blood supply, bone grafting should be indicated.

The aim of this study was to describe the embryologic and foetal development of the anterior paraclinoid region and more precisely the relationship of the internal carotid artery to the dura mater. This has been done by examining a collection of histological sections, representing a continuous series of 48 embryologic and foetal specimens, covering the period of the first 6 months of intra-uterine life. Neurological and vascular elements develop during the embryologic period; the internal carotid artery is recognizable in the various sections of its course and acquires a histological adult parietal constitution. The foetal period corresponds to the development of the meningeal structures. The superior, medial and lateral walls appear on the fifteenth week of amenorrhoea and do not change after that. The internal carotid artery enters subarachnoid space accompanied by a sleeve of mesenchymatous cells, which fixes it to the anterior clinoid process. The constitution of this sleeve, arising from the superior wall of the lateral sellar compartment, remained independent of the principle vascular part, which allows the formation of a plan of cleavage. The foetal relations of the dura mater and the internal carotid artery were seen to be different from those of adult subjects described in the literature, suggesting an existence of period of maturation postnatally.

The supraclavicular (intermediate) and supra-acromial (lateral) branches of supraclavicular nerves contribute to the innervation of the thorax, shoulder, and neck. Despite their clinical and surgical interest, they are not often considered for descriptive anatomy. The goal of this work was to clarify the morphometric knowledge of these two branches and to discuss the clinical relevance of the anatomical features. Intermediate and lateral branches of supraclavicular nerves of 14 necks (8 embalmed cadavers) were dissected using magnifying glasses. Macroscopic parameters were measured and nerve relationships were recorded. In 12 cases, the intermediate and lateral branches arose from a common trunk behind the posterior border of the sternocleidomastoideus muscle, at a mean distance of 96 mm (70–137) from the sternal angle. The intermediate branch divided into two or three secondary rami. Its most internal ramus crossed the middle third of the clavicle and its most external ramus crossed the second lateral quarter of the bone. The distance between the two farthest nerve endings of this branch was at mean of 98 mm (85–125). The mean distance of the most distal nerve ending from the clavicle was 46 mm (30–63). The lateral branch divided into two or three rami in eight cases and did not divide in six cases. Its most anterior rami crossed the trapezius muscle at a mean distance from the clavicular insertion of 17 mm (12–24). In 13 cases, these rami ended posteriorly or at the level of the anterior border of the acromion process and in 12 cases, they ended laterally or at the level of the acromion process with a mean distance 10.4 mm (0–24). In case of deficiency of these nerves, pain or sensitive deficit can occur without motor trouble. The factors of acute or chronic injury are direct compression, nerve stretching, repetitive stresses, and direct wound. Moreover, several neck or shoulder surgical approaches are dangerous for these nerves.

Introduction les deux greffons les plus utilises, Zaidemberg sur l’artere supraretinaculaire entre les premiers et deuxiemes compartiments des extenseurs, et Kuhlmann sur l’artere transverse anterieure du carpe, ont ete decrits pour le traitement des pseudarthroses atrophiques du scaphoide en seconde intention, et la necrose du lunatum. L’etude du territoire de recouvrement et des caracteristiques anatomiques propres permet de preciser et d’etendre leurs indications. Materiel et methodes 9 mains injectees au latex ont ete abordees, au besoin a l’aide de loupes agrandissant 3 et 6 fois, par une voie dorso-radiale pour le greffon de Zaidemberg, et anterieure de scaphoide pour celui de Kuhlmann. Nous avons mesure l’arc de rotation de chaque lambeau sans et avec la reserve de mobilite de l’artere radiale sans tension. Le calibre de chaque pedicule a ete mesure apres inclusion et section transversale. Resultats Le greffon pedicule anterieur : son origine est constante, 0,5 a 1 cm en amont de l’interligne radio-carpien, il recouvre le scaphoide, le semi-lunaire, les interlignes scapho-lunaire et luno-capitatum, au besoin en utilisant la reserve radiale, et ce meme si le greffon est pedicule sur l’artere ulnaire lorsque cette derniere est dominante. Il est plus adapte au traitement des pseudarthroses du scaphoide, le defect osseux etant anterieur. Son calibre est plus important. Le greffon pedicule posterieur de Zaidemberg est de realisation plus difficile du fait des variations anatomiques. Il permet d’atteindre le scaphoide mais inconstamment son tubercule proximal, le trapeze, le trapezoide, et les espaces scapho-trapezo-trapezoidien et trapezo-metacarpien. Conclusion ces deux greffons meritent d’etre connus et utilises, non pas en les opposant mais en les employant a bon escient, chacun ayant un territoire de recouvrement privilegie.

But l’utilisation d’un lambeau composite myocutane de gracile peut etre compliquee par la survenue d’une necrose partielle ou totale de la palette cutanee. L’objectif de notre etude etait de decrire l’anatomie de la vascularisation du muscle gracile et de la palette cutanee correspondante, pour tenter de mieux comprendre les afferences arterielles de la partie cutanee, et definir la topographie d’une zone cutanee transferable en plus grande securite. Materiel et methode la dissection de 32 cuisses de corps humains adultes donnes a la science a permis : 1) Une injection selective de bleu de methylene dans le pedicule principal du gracile, la mesure de la palette cutanee coloree par ses deux plus grands diametres et le calcul informatique de sa surface (imagej software). 2) Une injection selective de latex fluide colore pour identifier et decrire les vaisseaux perforants entre le corps musculaire du gracile et la palette cutanee. Resultats le pedicule principal du muscle gracile naissait de l’artere femorale profonde ou de l’artere femorale commune, et penetrait dans le muscle 90,55 mm sous le pubis avec un diametre moyen de 1,32 mm. Le muscle etait aussi vascularise par 1 a 4 pedicules accessoires. Une palette cutanee etait constamment coloree, localisee en regard des tiers proximal et moyen du muscle, de dessin complexe, de longueur moyenne 127,5 mm et de largeur moyenne 91,66 mm. Le calcul informatise de la surface de la palette cutanee donnait une valeur moyenne de 88,08 cm2 (59 a 120,95). Chaque muscle avait 2 a 6 vaisseaux perforants, issus de la face opposee au pedicule principal, compris dans un segment de 48 mm de long et se divisant au niveau sous-cutane. Un modele mathematique permettait de correler la surface cutanee au nombre de vaisseaux perforants myocutanes. Conclusion la determination de la surface de la palette cutanee transferable avec le muscle gracile, a partir du reperage par echodoppler de haute frequence du nombre et de la position des arteres perforantes permet de proposer des conditions plus fiables de prelevement du lambeau myocutane de gracile pour diminuer le risque de necrose cutanee.

L’elaboration embryologique de la region paraclinoide anterieure au sein de la loge parasellaire est decrite dans une etude qui repose sur une collection de coupes histologiques representant une serie continue de 48 specimens embryonnaires et fœtaux couvrant les six premiers mois de la vie intra-uterine. La periode embryonnaire permet la mise en place du contenu vasculo-nerveux de la loge latero-sellaire. Les parois superieure, mediale et lateral apparaissent definitivement constituees a la quinzieme semaine d’amenorrhee. L’artere carotide interne rejoint les espaces sous-arachnoidiens accompagnee d’un manchon de cellules mesenchymateuses qui la fixe a l’apophyse clinoide anterieure. La paroi mediale est double, composee de la loge hypophysaire et du perioste sphenoidal. La paroi laterale est composee de deux feuillets de nature identique mais d’architecture distincte. Le feuillet superficiel correspond a un feuillet de dure-mere epais qui accompagne les nerfs oculomoteurs vers la fissure orbitaire superieure, le profond a un reseau plus lâche donnant une cohesion a l’ensemble de ces nerfs. Les rapports fœtaux entre dure-mere et artere carotide interne different de ceux decrits chez l’adulte, traduisant une periode de maturation post-natale. Les resultats de cette etude sont en faveur d’une evolution de la nomenclature, le terme de defile inter periosto-dural traduisant plus fidelement la nature des parois du compartiment latero-sellaire. L’existence d’une communication entre les deux regions latero-sellaires remet en cause les theories precedentes. Enfin, le reseau veineux, reparti autour de l’artere carotide interne, s’immisce au sein de la paroi laterale, permettant d’expliquer certaines complications hemorragiques chirurgicales.