The French Southern and Antarctic Lands (TAAF) form the most remote and isolated territory of our country. Beyond their exceptional historical and natural heritage aspect, they host high-level scientific bases dedicated to research work in a wide variety of disciplines, such as oceanography, glaciology, meteorology, animal and plant biodiversity, or even astronomy, the results of which concern the entire planet and all its life forms. These scientific bases, permanently occupied, require not only a medical presence but also surgical skills, in particular during the austral winter making it impossible to evacuate. The conditions of surgical practice in the Southern Territories remain unique today, although they have points in common with war surgery or humanitarian surgery. Having an operating room with the possibility of general anesthesia and increasingly efficient equipment, the doctors present on the southern bases are rarely trained surgeons and without access to CT or MRI imaging. . After carrying out an onboard mission on "L'Astrolabe" as flight doctor and scientist (TAAF/ French Polar Institute Paul -emile Victor, rotation 2 Hobart-Australia/ Dumont-Durville-Terre-Adelie scientific base), we organised, since 2015, a practical surgery course intended for doctors wintering on the scientific bases of the French Southern and Antarctic Lands (TAAF) which it is instructive to take stock of: 1) educational strategy developed to train practitioners working on these bases, 2) choice of surgical techniques taught and to be mastered, 3) learning opportunities during a surgical internship in a military hospital, 4) development of written and video teaching aids, 5) realization of a practical surgery course of a period of three days in the Anatomy Laboratory of the Faculty of Medicine, 6) comparisons with the organization of other countries with in Antarctica, and 7) prospects.
The National Professional Council (NPC), as in all specialties, was founded two years ago. It is an official body and a priority interlocutor with the supervisory authorities. This CNP has been linked to our learned society, the SOFCOT. It includes legal entities such as the SOFCOT, the RENACOT registry of orthopaedic surgery, the FICOT or orthopaedic surgery foundation, the National Syndicate, orthorisq delivering the accreditation of good practices, and finally the College of orthopaedic surgeons (CFCOT) responsible for the validation of the teaching of interns and continuing education. Finally, there are the partner societies of specialties (hip and knee, foot, pediatrics, hand, arthroscopy ....) which are mandated to deal with problems affecting a particular specialty. SOFCOT is the main funding society that is supported by the industry through its annual convention. The national professional council receives a limited premium from the government and receives dues from its member companies. The RENACOT receives funds from the SOFCOT to finance the launching of the register. The FICOT receives donations from the industry, which it anonymizes and allocates to educational grants. All these legal entities therefore have specific tasks. SOFCOT and its president organize the congress and scientific activities. RENACOT, which is taking off, will be in charge of patient relations and the medical patient record as well as the implant register allowing traceability. It will include mandatory data loaded from the operative report and follow-up data to activate the registry function and then sell the data to manufacturers to obtain certification of the implants. In addition to the accreditation, Orthorisq will also manage the health brick which includes the monitoring of the physical and mental health status of the surgeons, essential for the recertification. Finally, Orthorisq also validates the continuing education.
Post-thrombotic syndrome or post-thrombotic disease (PTD) is the set of chronic venous symptoms and/or signs secondary to deep vein thrombosis of the lower limbs. It manifests itself in 20% to 60% of cases within two years after the thrombosis. Evolution of the thrombotic vein is described. The diagnosis is clinical with the Vilalta score including 5 subjective criteria , 6 objective criteria with the presence or not of a leg ulcer. The diagnosis of PTD must be evaluated as soon as possible by echo-doppler. This pathology is responsible for an alteration in the quality of life and a burden in public health e linked to leg ulcers, which are present in 5% of cases. Recommendations have been published with the aim of reducing the occurrence of PTD through early treatment of thrombosis and the prescription of medical elastic compression. In severe post-thrombotic syndromes, new recanalization therapies can reduce venous hypertension and recurrence of leg ulcers. Deep vein surgery with valvular repair has the same objectives.
Nosocomial infections, so called healthcare-associated infections (HAI), occur in about 1 of 20 in-hospital patients. Most of these infections are caused by pyogenic bacteria in urinary tract (30%), lower respiratory tract (20%), blood stream (10-15%) or surgical site (10-15%). They occur mostly in intensive care units and in patients with underlying conditions (elderly, immuno-compromised, etc.). Their associated mortality, potential disability and extra financial cost have a significant impact on the healthcare system. A part of HAI are caused by multidrug-resistant organisms. Nowadays, highly or totally drug-resistant bacteria are emerging, rending the antibiotic treatment ineffective (ex: carbapenemase-producing enterobacteria). Surgical site infections raise particular problems in terms of diagnosis and post-operative follow-up, especially for ambulatory surgery. The occurrence of delayed infections in patients undergoing hip or knee prosthesis surgery should be also considered. Control of HAI is organized for more than 25 years in France, based primarily on the implementation of standard hygiene precautions, rationalized antibiotics usage, and epidemiologic surveillance to provide indicators of effectiveness. These measures are the keys of a global policy for improving patient safety all along the patient cares from the hospital to the community.
The first-line treatment of cerebral tumors or low-grade epilepsy-associated neuroepithelial tumors starts by surgical resection. The extent of resection is related to progression free survival and overall survival for patients suffering from brain tumors, and to the seizure control in patients harboring low-grade epilepsy-associated neuroepithelial tumors. Nowadays, no operative tool allow to know precisely and in real time the tissue's nature during glioma resection: healthy tissue, infiltrated tissue or tumor? Optical imaging has developed significantly at the end of the 20th century and at the beginning of the 21st century: it is possible to obtain information about the tissue's nature with a micrometric resolution and fast acquisition. Concerning surgical oncology, optical imaging seems able to guide the surgeon during tumor resection, in order to remove pathological tissue while respecting healthy tissue. This article summarizes the experience of the Sainte Anne Hospital in optical imaging with two complementary methods: the tissue endogenous fluorescence analysis with two-photon microscopy in collaboration with the IMNC laboratory and the full field optical coherence tomography in collaboration with the Langevin Institute. Endogenous fluorescence is obtained without any dye: the biological tissues possess naturally fluorescent molecules. Endogenous fluorescence analysis can be realized with two-photon microscopy: it allows to obtain 4 different optical contrasts: spectral imaging, fluorescence lifetime, second harmonic generation signal and fluorescence. This optical imaging method exhibits a fast acquisition time and a micrometric resolution. Endogenous fluorescence analysis of fixed fresh human brain samples showed that there were significant differences between tumor and healthy tissue.
Surgery for head and neck cancer involve opening and resections of large areas of the upper aero-digestive tracts, of the sinonasal region, or of the skull base. Surgery has a high rate of acute and chronic toxicity, morbidity and sequels, in a large range of criteria associated with the quality of life regardless of the outcomes of the treatment on the disease survival: functional sequels, infectious complications, aesthetic morbidity, and social deterioration. Minimal-invasive surgery and reconstructive surgery both have been developed in parallel with the same objectives of improving the quality of life by decreasing the morbidity and the sequels of treatment. Nevertheless their means of action are separate and independent: vanishing of the morbidity and sequels of the surgical approach on the one hand, diminishing the morbidity and sequels of consequences of the surgical resection on the other hand. Both those parallel means of action are sometimes convergent in a very small number of indications and in few patients in expert centers and by experimented teams, especially in endoscopic endonasal skull base surgery and in salvage transoral robotic oropharyngectomy.
In the late 1990s the first French consensus conference on postoperative pain care elaborated a modern and ambitious management strategy of postoperative analgesia in adults and children. Prior audits on this subject have been disturbing. The concepts of protocols, multimodal analgesia, self-controlled analgesia, and mandatory assessment of the pain level were first developed. These references helped to guide clinicians in improving the quality of care. In a ten year period the pain management has been individualized. Risk factors of severe pain in the post anesthesia care unit, or chronic pain, are now identified before the surgery. The concept of vulnerability to pain allowed the implementation of combined analgesia individualized for patients' needs including those at a distance from surgery. Patients of extreme ages were considered as well-a specific pain evaluation scale for non-communicating patients has been validated. The knowledge of pharmacogenomics and patient's personal history is actually a priority for risk management especially in case of opioids use. Pharmacological meaning of " titration" defines analgesia which fits patients' needs while limiting opioid doses. However, it is a synergistic interprofessional collaboration that allows patients to benefit from better healthcare delivery including pain control.
We reviewed 1029 cases operated on in 2003. Within them, we had 428 cases with clinical reviews and MRI were used for this study. Prelimary we validated our clinical methodology and the analysis of healing and functional value of the muscles, simplifying Sugaya classification into 2 groups and fatty infiltration according to Goutallier into 2 groups, doing a preliminary study of the inter and intra reproducibility. * The group of isolated supraspinatus tears (SSP) was the most important (289c) and had the best results: the Constant score (CS) increased from 52 preoperatively to 78 points, or 104% for the weighted score by age and sexe. 80% were healed. The results were influenced by the quality of cicatrisation. The long head of the biceps could be preserved if normal. * The group of isolated subscapularis tears (SSC) (35 c) had a 90% healing rate and a CS = 75 points. * The group of antero-superior tears (SSP+ SSC), (92 c): had satisfactory results at 10 years: 77 pts and 100 % in weighted CS. The postoperative CS was influenced by the size of the lesion of the SSC and the biceps but was not influenced by the tendon healing! SSV is influenced by the healing. Tendon healing is not influenced by the size of lesions. SSP healing effect healing SSC. Postoperative fatty infiltration of the SSC, frequent, is influenced both by the healing of the SSC and SSP. The anterior superior rupture extended to all SSC remains a severe injury for which compensation provides more limited results! * Severe lesions, involved 3 tendons had CS= 78 pts, but this group was more aged, with 32% of severe Fatty Infiltration, 30% of retears and 10% of osteoarthritis. * It was the same for postero-superior ruptures. * The risk of osteoarthritis was related to age, preop stiffness, the type of tears: Supra + complete SSC: 22%! * The comparison between open and arthroscopic repair has shown no significant differences in terms of healing or clinical results, but a little more osteoarthritis in case of open surgery. * Complications were 13.6% with 9% reoperations. We reviewed 322 cases for rotator cuff tears operated on 1994. We were able to analyse 126 shoulders with clinical results and 97 patients with clinical AND MRI. * Concerning repairs of isolated supraspinatus tears: Two-thirds of the patients had a shoulder that is at least 80% of a normal shoulder (SSV> 80% = 62%). The Constant score (CS) remained above the preoperative score: 71 pts, 58% of repaired tendons were healed after 20 years. The shoulders healed were better than unhealed. 91% did not need reoperation. 3% were converted into total shoulder prosthesis. 87% of patients without arthritis or moderated osteoarthritis. The complication rate was 11%. The most predictive factor for clinical outcome after surgery is the Fatty Infiltration of the infraspinatus. Concerning massive tears (2 tendons and more) -The results were not statistically different: CS = 68 pts SSV> 80%: 55% The complication rate was 11% We observed 53% of healing and 21% of osteoarthritis
The Dipleme Inter Universitaire (DIU) de Traumatologie Viscerale (TV) is a university education program intended for surgeons in training or in activity, complementing the surgical training curriculum. Its aim is to provide the necessary elements to enable surgeons to deal with trauma care activities within emergency units, focusing in particular on the management of polytrauma patients and massive casualties.
Introduction: the outcomes of arthroplasty are generally disappointing when a major compromise exists in the rotator cuff. In these cases, Grammont-type reverse shoulder arthroplasty (RSA) can be used and satisfactory outcomes have been reported. The goal of this study was to evaluate the outcomes of RSA after more than 10 years of follow up and to analyze the effects of preoperative etiology on those outcomes. Materials and Methods : it was a retrospective multicentric study about 145 RSA divided in 3 etilogies: group A cuff tear arthropathy (CTA) and massive cuff tear (MCT), group B-revision of hemi or total shoulder arthroplasty, group C : miscellanous. Survival curves were established with the Kaplan-Meier technique. Clinical outcomes were assessed by Constant score and range of motion. Results: The survival curve to prosthetic removal showed an overall survivorship of 92% at 10 years and 84% at 15 years. At 10 years, segmentation according to etiology showed a 97% survivorship for group A and 88% for group B. Constant score and active anterior elevation have significantly improved. Active external rotation has not improved. The majority of complications take place during the first 3 years. Discussion and Conclusion: Survival rate at ten years is pretty good mainly for group A for which RSA should be reserved primarily.
Place of indocyanine green coupled with fluorescence imaging in research of breast cancer sentinel node The sentinel node has a fundamental role in the management of early breast cancer. Currently, the double detection of blue and radioisotope is recommended. But in common practice, many centers use a single method. However, with a single detection, the risk of false negatives and the identification failure rate increase to a significant extent and the number of sentinel lymph node detected and removed is not enough. Furthermore, the tracers used until now show inconve-niences. The purpose of this work is to present a new method of detection, using the green of indocyanine coupled with fluorescence imaging, and to compare it with the already existing methods. The method combined by fluorescence and isotopic is reliable, sure, of fast learning and could constitute a good strategy of detection. The major interest is to obtain a satisfactory number of sentinel nodes. The profit could be even more important for overweight patients. The fluorescence used alone is at the moment not possible. Wide ranging studies are necessary. The FLUOTECH, randomized study of 100 patients, comparing the isotopic method of double isotope technique and fluorescence, is underway to confirm these data.
The posterior approach to the entire myopectineal orifice of Fruchaud via an abdominal incision with the insertion of a large prosthesis completely overlapping all orifices has been popularised by Stoppa since 1980. Since 1990, the Stoppa technique has been performed endoscopically, by means of both the transperitoneal (TAPP) and preperitoneal (TEP) approaches. In 2009, the European Hernia Society published evidence-based guidelines for the treatment of inguinal hernias. Grade A recommendations: for the repair of recurrent hernias after conventional open repair, endoscopic inguinal hernia techniques are recommended. When only considering chronic pain, endoscopic surgery is superior to open mesh. It is recommended that an endoscopic technique is considered if a quick postoperative recovery is particularly important. From a socio-economic perspective, an endoscopic procedure is proposed for the active working population, especially for bilateral hernias. These recommendations may seem paradoxical because it is illogical to recommend the use of this technique to surgeons not particularly pulled in this procedure. Nevertheless, as the advantages of the laparoscopic approach are recognized as being the best, why shouldn't we recommend it for all patients? Thus, for an experimented surgeon, TEP could be a Gold Standard for any cases, easy or difficult.
The establishment of a trauma network improves the efficiency of patient care. Trauma registries can be used to measure the effectiveness of the network, but also to adapt resources and guide health policies. However, the logistics of existing registers in other countries are complex and costly. In France, there is not yet a structured trauma network or a national trauma registry. The means available to evaluate trauma activity are limited: epidemiological surveys, road traffic accident registers, and severe regional trauma registries (eg TRENAU in the Northern Alps). The analysis of medical activity through the Program of Medicalization of Information Systems (PMSI) allows a global but limited vision of the importance of this activity. Therefore a study was conducted to illustrate the public health issue related to trunk trauma in France. The preliminary results are presented in this paper. Traumatic lesions of the trunk were present in 1% of patients hospitalized in medicine and / or surgery in 2015 (121,528 patients). Patients were treated in 56% of the cases in the General Hospital Center, 29% in the Regional and / or University Hospital Centers, and 15% in the private sector or equivalent. A passage in intensive care was necessary for 17% of the patients and mortality was 2.25%. A transfer to another medical structure was carried out in 29% of the cases. These partial data, as well as preliminary (such as Traumabase) or regional experiments, will allow the establishment of a formal trauma network at the national level with the establishment of an effective registry.
Following the tragic events caused by urban terrorist attacks in Paris, November 2015, seven departments of orthopedic and trauma surgery have compared their management of the casualties. Three notions have been debated: the characteristics of gunshot wounds, the management of flood and the surgical indications on emergency. The conclusion was the need for a specific learning on "triage" and surgical damage control.
In application of the article L. 1142-1, II, of the public health code, and the jurisprudence of the Council of State (Conseil d'Etat) and the Court of Cassation, the national solidarity, by means of the ONIAM, takes care of the compensation of the medical accidents having entailed an IPP of at least 25%, arisen without fault of the practitioner, provided that this accident is characterized by: - Consequences strikingly graver than those to whom the patient was exposed in a likely enough way in the absence of treatment - Or consequences which are not strikingly graver, but which occurred in conditions where the emergence of the damage presented a low probability. So, the consequences of the accident cannot be considered as abnormal when the gravity of the state of the patient led to practice an act entailing high risks. The therapeutic failure is excluded from the compensation by the national solidarity. The expert doctor, whose appreciation is essential for the judge, will have to look for: A) Which would have been in a likely enough, short and medium-term way, the state of the patient in case of therapeutic abstention? B) If the medical act entailed consequences "strikingly graver" that those to whom the patient was displayed in a likely enough way in the absence of processing; C) In the denial: - If the incurred risk was weak with regard to the conditions where the act was carried out, with regard to the health of the patient and the circumstances (emergency absence, not committed vital risk, bearable pain); - Or if the risk was brought up, but the act justified because of the gravity of the state of the patient (fatal risk, urgency).
Glioblastoma is the most frequent and the most aggressive primitive brain tumour in adults. Prognosis remains poor with 5-year survival rates of only 5%. Maximal safe surgical resection, which is the gold standard as firstline therapy, is a major prognostic factor. To improve the onco-functional balance, it is mandatory to protect the healthy brain tissue while maximizing the resection of tumor tissue. However, current image-based surgical tools (MRI, neuronavigation, and ultrasonography) do not allow to accurately distinguish tumor tissue from healthy brain tissue. In this context, the intraoperative induced fluorescence has been developed. The preoperative injection of a fluorescent dye -the 5-aminolevulinic acid -to the patients with a glioblastoma allows locating intraoperatively the glioma cells, which preferentially absorb the dye and became fluorescent after an appropriate light excitation. The intraoperative induced fluorescence can already be used in current neurosurgical clinical practice using an operating microscope specially equipped: it increases both the extent of resection and the progression-free survival, as a consequence. However, this macroscopic detection has a limited spatial resolution. So, various neurosurgical groups, particularly those of the Barrow Institute (Phoenix, USA) and of the Pierre-Wertheimer Hospital (Lyon, France), develop high-resolution detection devices of the intraoperative induced fluorescence with confocal microscopy. Their preliminary studies highlight the possibility to detect glioma cells at the cell spatial scale, in real time during surgical resection. The optical imaging can improve the management of patients harboring a glioblastoma, leading to a better and safer surgical resection and improving both the survival and the quality of life of these patients.
A road trauma registry has been in use since 1995 in the Rhone County. It covers the Rhone area (1.6 million inhabitants). Its objectives are both knowledge of road trauma and its consequences. The inclusion criterion is a road traffic accident involving at least one vehicle, motorized or not, occurring in the Rhone county and requiring health care activity. Inclusion of a casualty in the Registry is the result of the cooperation of 245 health care facilities, from emergency departments, intensive care units, surgery. to rehabilitation departments. Information collected for every casualty consists of crash characteristics (type of road users, location, date, time of day) and of the following characteristics; gender, date of birth, place of residence, hospital stay, hospital transfer and a description of the injuries sustained. For every subject, injury assessment is based on the whole set of diagnoses provided by the different health services the subject has gone through. Plain text diagnoses are coded by the registry physician according to the Abbreviated Injury Scale (AIS) 1990 revision. The registry has been approved by the French National Registry Committee.
