Reported wound complication in below knee surgery can be quite high. Recent study demonstrated that increased blood loss and hematoma formation increase wound complications especially in foot and ankle surgeries. Despite the evidence on the benefit of TXA on blood loss in TKA and THA it is not routinely used by surgeon in below knee surgery.

To assess the efficacy and safety of this medication in reducing wound complication and blood loss and the risk of thromboembolic complications in patients undergoing below knee surgery. A systematic literature search of PubMed, Embase, Ovid, the Cochrane Library and AAOS and AOFAS conference proceedings was conducted. The primary outcome was the rate of wound complications. Data were analyzed using the Review Manager 5.3 software.

Nine studies involving 861 patients met the inclusion criteria. The meta-analysis indicated that TXA, when compared to a control group, reduced wound complications (OR, 0.54; 95% IC, 0.31 to 0.95, p = 0,03), blood loss (MD = −149,4 ml; 95% CI, −205,3ml to −93,6ml), post-operative drainage (MD = −169,8 ml; 95% CI, −176,7 to −162,9 ml) and hemoglobin drop (MD = −8,75 g/dL; 95% IC, −9,6 g/dL to −7,8 g/dL). There was no significant difference in thromboembolic events (RR 0,53; 95% CI, 0,15 - 1,90; p = 0,33).

This study demonstrated that TXA could be use in below knee surgery to reduce wound complication and blood loss without increased thromboembolic complications. The small number of studies limit the findings interpretation. Further studies are needed to sustain those resutls.

There is no clear consensus regarding the indications for surgical treatment of middle third clavicle fractures. An initial shortening of 2 cm or more of the clavicle was associated with poor clinical outcomes and higher rate of non-union. The number needed to treat (NNT) clavicle fractures in order to prevent non-union ranges in the recent literature from 4.5 to 9.2. A direct relationship between shortening of the clavicle and a poor clinical outcome has not yet been demonstrated.

Prospective cohort study performed in a Level one trauma centre including 148 clavicle fractures treated conservatively. Eighty-five patients met the inclusion criteria (healed fracture in the middle third, no other upper limb lesions) and 63 were enrolled. A single assessment was realised at a minimum one year follow-up by an independent examiner and consisted in Constant and DASH scores, range of motion, strength in abduction (Isobex) and a specific radiographic evaluation using a calibrated AP radiographs of both clavicles. Two groups were constituted and analysed according to a radiologic shortening > 2 cm (patients and assessor blinded). Sub-analyses were performed to find any relevant clinical threshold.

The rate of shortening > 2cm in this cohort is 16.1% (10 patients). No clinical differences between the two groups for Constant scores (shortened > 2 cm = 96.0 ± 6.0 vs 95.2 ± 6.6, p=0,73) and DASH scores (8.4 ± 11.9 vs 5.4 ± 8.1, p=0,32). A slight loss in flexion was observed with a shortening > 2cm (175 deg ± 8.5 vs 179.3 ± 3.4, p=0,007). No clinical threshold (in absolute or relative length) was associated with lower functional scores. No relationship between clinical results and patient characteristics. Interestingly, cosmesis was not an issue for patients.

This study could not demonstrate any clinical impact of the shortening of the clavicle in patients treated conservatively for a fracture in the middle third. Functional scores are excellent and the slight difference in flexion is not clinically significant. We were not able to found patients unsatisfied with their treatment. The poor functional outcomes described in previous studies are mainly related to non-unions. Just after the trauma, protraction of the scapula and single AP views centered on the clavicle can overestimate the real shortening. An initial shortening of the clavicle > 2 cm is not a surgical indication for fractures in the middle third; patient selection for surgery should focus on risk factors for non-unions.

Purpose of the study: Balistic nerve injury is not common in civil medicine. We analyzed a series of 30 patients who underwent surgery for this type of injury suffered in the Gaza strip between 2002 and 2004. All patients presented paralysis of the sciatic nerve or one of its major branches. All injuries were caused by war weapons.

Material and methods: The series included 28 men and two women, mean age 22 years (range 2.5–65). The injury had occurred more than one year earlier for 33% of patients. The injury was situated at the knee level in twelve patients and in the thigh in ten. Complete nerve section was observed in 12 patients and partial section in two. Loss of nervous tissue was significantly greater for lesions around the knee. Nineteen patients underwent surgery for: neurolysis (n=3), direct nerve suture (n=8) and nerve grafts (n=8). Eleven patients were reviewed at mean 13.7 months (range 3–30 months). There were no failures. Results of reinnervation of the tibial nerve territory were better than for the fibular nerve. Sixteen patients underwent palliative transfer for a hanging foot for more than six months: 15 transfers of the posterior tibial muscle through the interosseous membrane and hemitransfer of the Achilles tendon. Seven patients underwent Achilles tendon lengthening at the same time and five had a reinnervation procedure on the common fibular nerve.

Results: Seven patients were reviewed with a mean follow-up of 1.8 years (range 4–30 months. None of the patients used an anti-equin orthesis. There were three cases of forefoot malposition. The overall Stanmore score was good at 75.4/100 (range 59–100).

Discussion: High-energy ballistic trauma creates a specific type of injury. Nervous surgery can be indication early to favor spontaneous recovery. Palliative surgery for fibular lesions provides regularly good results.

Conclusion: Nerve injuries due to ballistic trauma should be explored surgically because of the possibility of direct nerve repair. In addition, depending on the type of paralysis, reliable palliative surgery can be proposed.

Purpose: Trapezometacarpal osteoarthritis is frequent in women aged over 50 years. Surgical cure may be needed after failure of well conducted medical treatment. When the trapezeal bone stock is insufficient for implantation of a total prosthesis, total trapezectomy can relieve the pain. This procedure is generally associated with stabilization ligamentoplasty of the first ray. The purpose of this study was to demonstrate the feasibility of this procedure using an arthroscopic approach and to detail the technique and its limitations.

Material and methods: This study was conducted on twelve cadaver specimens from eleven women and one man, mean age 85 years. Radiographs were obtained to confirm the trapezometacarpal osteoarthritis. Standard arthroscopic material used for the wrist was employed (2.4 mm optic, mini-shaver). Two portals on either side of the abductor pollicis lungus tendon were used to approach the trapezometacarpal joint. Total trapezectomy was performed with the mini-shaver distal to proximal. A tendon band measuring 6 to 7 cm was fashioned from the abductor pollicis longus tendon via a proximal contraincision. This band inserted on the first metacarpal was passed through two bone tunnels bored in the base of the first and second metacarpals then fixed to the base of the second metacarpal. Operative time was noted. The quality of the bone resection was determined on postoperative radiographs and open inspection.

Results: Arthroscopic total trapezectomy with stabilisation ligamentoplasty was achieved in all cases and evaluated radiographically and at open inspection. No lesions to noble elements were observed.

Discussion: This minimally invasive technique for trapezectomy associated with stabilisation ligamentoplasty was found to be feasible but did require a certain degree of learning. We were unable to identify any procedure-related morbidity, particularly concerning the sensorial branch of the radial nerve to the thumb.

Conclusion: The results of this preliminary study are encouraging and suggest a clinical trial should be conducted to prove the advantages of this technique in terms of morbidity and socioeconomical cost.

Purpose: Appropriate management of complex trauma of the upper limb (CTUL) is a significant therapeutic challenge. The main difficulty is to determine in an emergency situation when ambitious conservative surgery is legitimate and when amputation in necessary. We propose a prognostic lesion score to determine the best option in the emergency setting.

Material and methods: This study included 48 patients operated on between 1987 and 1997. These patients presented total or partial amputation (n=23), devascularising injury with continuous limb (=7), complex non-devascularising injury with continuous limb (n=18) (Gustilo IIIa and IIIb). Isolated hand trauma was excluded. Each patient was attributed retrospectively a lesion score taking into account each tissue (bone, vessels, nerves, muscles, skin). At minimum two-year follow-up, the outcome was evaluated for the amputated or non-amputated limb. For each non-amputated patient, a more precise outcome was established using the Chen classification. Operative procedures used the same protocol for all patients.

Results: Considering the functional results, the statistical analysis enabled identifying prognostic factors for amputation among the five variables studied. Analysis using a classification tree enabled development of a decisional algorithm based on the muscle, nerve and skin injuries which provided 64.7% sensitivity and 100% specificity with a 100% positive predictive value and an 83.8% negative predictive value. A multiple logistic model was used to confirm these results and led to the selection of the same variables.

Discussion: The CTUL score is easy to use and is the only one in the literature using only variables statistically proven to have significant prognostic value for CTUL. Surgical experience is however indispensable for appropriate decision making in these emergency situations. This score thus provides an important therapeutic aid useful in borderline cases where amputation is discussed.

Conclusion: A prospective study including a larger number of patients would be helpful to better detail indications and preserve the 100% specificity for an irreversible therapeutic decision.