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While the first conflicts of the 21st century involved asymmetric warfare in the fight against terrorism, recent geopolitical events require us to prepare for the possibility of high-intensity conflicts. Modern wounding agents mainly consist of explosive devices and high-velocity bullets. Every trauma surgeon must be familiar with the mechanisms of injury specific to armed conflicts. The initial care of these injuries is based on applying damage control surgery to save the patient's life, save their limb if possible and preserve their function. Blast injuries are the most common in modern armed conflicts; the resulting combination of severe injuries can be challenging to treat. Limb reconstruction involves a sequential strategy based on simple, reliable and reproducible techniques which can be used by non-specialized surgeons working in sometimes austere situations. LEVEL OF EVIDENCE: Expert opinion., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Masson SAS.)

Introduction: A poorly treated acute ankle sprain can rapidly progress to chronic instability, with varying degrees of disability secondary to weakness of the ankle stabilizers. The aim of our study was to evaluate functional scores and physical tests in the assessment of eversion and proprioception deficits after non-surgical treatment of chronic ankle instability. Our hypothesis was that these functional scores and physical tests are suitable and sufficient for assessing the functional aspect of an unstable ankle., Material and Method: This was a prospective, single-center study of patients managed for chronic ankle instability between November 2020 and November 2021. An ankle assessment was performed using two functional scores, the Foot Ankle Ability Measurement (FAAM) and the Ankle Ligament Reconstruction - Return to Sport after Injury (ALR-RSI), as well as two validated physical tests (Y-Balance Test and Side Hope Test). An objective (quantified) assessment of stabilizer muscle strength and proprioception was carried out using a connected device (Myolux™ Medik e-volution)., Results: At last recoil, twenty-eight unstable ankles were included. Only the ALR-RSI score correlated strongly with Myolux™ assessment of eversion strength (Rho ()ρ = 0.7; p < 0.001), and proprioception (Rho ()ρ = 0.8; p < 0.001). FAAM and physical tests were not or only very moderately correlated with Myolux™ assessments., Discussion: In the absence of the Myolux™ test, the ALR-RSI score seemed the most suitable functional assessment of an unstable ankle in contrast to the FAAM score and the physical examinations Y-Balance Test and Side Hope Test., Level of Evidence: IV; prospective study., Competing Interests: Declaration of competing interest OB is a consultant for Arthrex (courses), Dedienne Santé and Movmedix. CC is a consultant for Newclip and Stryker. All other authors declare that they have no links of interest., (Copyright © 2025 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Introduction: Medial opening wedge high tibial osteotomy (MOWHTO) is a surgical option for medial femorotibial osteoarthritis, which preserves articular cartilage by correcting the extra-articular deformities of the lower limbs that cause osteoarthritis. This is an increasingly popular treatment in a population with high functional demand, such as the French military population. The aim of this study was to evaluate the rate of return to work and military activities at 6 months postsurgery and at last follow-up in this military population following MOWHTO.The hypothesis of this study was that MOWHTO enabled a majority of service members to return to the same level of activity within 6 months of surgery., Materials and Methods: This was a retrospective, multicenter study including all French military personnel operated on for MOWHTO alone for osteoarthritis of medial compartment between 2008 and 2018 in different Military Teaching Hospitals. We excluded civilian patients. For each patient, a questionnaire was used to collect epidemiological, professional, sports, and functional data. The primary endpoint was the rate of return to work at 6 months postsurgery. We also studied the recovery of sports activities and functional results at a 6.6-year follow-up by standardized questionnaires (Tegner activity scale, Lysholm, IKDC subjective (International Knee Documentation Commitee))., Results: Twenty-four MOWHTOs were performed during this period in a cohort of 22 French military personnel. Return to work at 6 months was possible in 20/24 cases (83.3%). Of the four patients who did not return to work at 6 months, two changed their activities, while the other two returned to their jobs after 6 months. The rate of resumption of sporting activities at an equal or higher level was 50% (11/22). There was no difference between pre- and postoperative Tegner Activity Scale scores at the longest follow-up (P = .08). The mean postoperative Lysholm scores were 73.5 (standard deviation 17.8) and IKDC 59 (standard deviation 8.7). No intraoperative complications were found, and one case of postoperative infection was found., Conclusions: A total of 83% of the operated soldiers were able to return to their professional activities in less than 6 months. We observed a functional improvement at the last follow-up. Comparing these results with data from civilian populations, the rate of occupational recovery is comparable. However, the return to sport is much better in the series of nonmilitary patients with approximately 90% return to work and sport in the year following surgery. MOWHTO improves the functional results of the knee, enabling a return to work and sport in most cases in young, active populations such as the French military., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Background: Symptomatic osteochondral lesions of the talar dome (OLTD) represent a real therapeutic challenge. In the absence of appropriate treatment, these lesions can evolve into tibiotalar osteoarthritis. Stage 3 lesion of the SFA classification and resistant to medical non-operative treatment may require surgical treatment. The results of the membrane-induced chondrogenesis (AMIC®) technique in the knee have been previously reported. At the ankle, few publications exist. Our objective was to evaluate clinical results of the AMIC® technique., Hypothesis: AMIC® technique is clinically effective for the treatment of LODT with a minimum follow-up of 12 months after surgery., Material and Method: This was a multicenter (5 centers) retrospective study including patients operated on for an OLTD stage 3 of SFA between January 2019 and March 2021 using the AMIC® technique with a ChondroGide® membrane. A functional assessment by questionnaire (AOFAS, EFAS, FFI scores), clinical (VAS) and return to sport were carried out., Results: 21 patients (10 men and 11 women), aged 16-69 years (mean age 34 years) were included. The average follow-up was 34 months (min 12 months; max 72 months). The average loss of substance was 1.83 cm 2 (min 0.6 cm 2 ; max 6 cm 2 ). The results showed a significant improvement in the AOFAS functional score which went on average from 71 [CI = 64; 77] to 90 [CI = 82; 97], EFAS which went from 15 [CI = 10; 20] to 32 [CI = 10; 20] = 26; 38], FFI which went from 28% [CI = 19%; 38%] to 10% [CI = 2%; 18%] and the EVA which decreased by 4 [CI = 3.9; 4.7] to 1 [CI = 0.5; 2.4]. 60% of patients returned to sport at the same level and 80% of patients were satisfied with the surgery., Discussion: AMIC® method improved the functional results of patients with SFA stage 3 OLTD at an average follow-up of 34 months post-operatively., Level of Evidence: IV; retrospective observational cohort study., Competing Interests: Declaration of competing interest M.P has received speaker and consultant honoraria from Geistlisch® Pharma. E.B, C.C, A.C and O.B declare they have no financial interests., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Purpose: Managing the distal tibiofibular (DTF) joint remains a challenge despite recent developments. Ankle arthroscopy is emerging as a diagnostic and therapeutic means. Our study aimed to compare preoperative imaging data and arthroscopic data, with the hypothesis that imaging alone is insufficient to evaluate acute laxity, and with arthroscopy as the reference examination., Methods: All patients treated in 2023 in our department for an acute isolated DTF lesion were included prospectively. Preoperative radiographic and MRI imaging were compared with arthroscopic data., Results: Ten patients were treated. For five patients, the instability was doubtful after carrying out an appropriate imaging assessment (X-rays of both ankles, MRI). For four of these five patients, instability was confirmed by arthroscopy. Arthroscopy was useful for suturing the anterior bundle of the DTF joint for two patients and allowed for verifying the reduction in the sagittal and coronal planes for two patients. No complications were detected., Conclusions: Arthroscopy in isolated acute DTF lesions seems to provide a diagnostic and therapeutic advantage. Its use may allow for exhaustive assessment and complete repair of lesions. It must be offered as soon as possible; a delay in specialized imaging may delay therapeutic care., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Introduction: Anterior cruciate ligament (ACL) rupture is frequently encountered in athletes as well as in military personnel. In civilian population, many studies have looked at the return to sport, but return to duty in Army is a topic that requires further research.The purpose of this study was to determine through annual military fitness tests in real conditions, the return to sport in soldiers after ACL reconstruction and factors influencing failure., Materials and Methods: This was a retrospective comparative study. Patients were all soldiers and had followed up in a Military Hospital. The SUCCESS group was military personnel who obtained a result of the specific aptitude test greater than or equal to this same test carried out before reconstruction of the ACL, the FAILURE group comprised the others. Results of the annual specific aerobic fitness tests were collected before and after ACL reconstruction. Preoperative epidemiological data, intraoperative information, and isokinetic test results were collected., Results: One hundred forty four soldiers were included between January 2011 and December 2017 (94.9% of men with a median age of 27.6 years); 40.3% obtained a result greater than or equal to the preoperative fitness test after ACL reconstruction. Among the soldiers who did not regain their performance, 24.3% were declared unfit or discharged. In the FAILURE group, we found patients with a higher body mass index (25.5 vs. 24.4; P = .04), less patients with isokinetic deficit < 30% on the knee flexors and extensors (26.6% vs. 62.9%; P < .01), more long sick leave (39.5% vs. 13.7%; P < .01), and late resumption of military activities (10.5 vs. 8.9 months; P < .01)., Conclusion: Rupture of ACL has a significant impact on the operational capacity of the French army. The proportion of return to the same level in annual specific fitness tests after ACL reconstruction is 40% among soldiers. Several variables are important to consider in the follow-up of these patients to optimize their recovery of sports performance and therefore their operational capacity., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To determine the rate and time of return to duty following anterior cruciate ligament reconstruction (ACLR) in military members, and to determine whether their outcomes are influenced by patient characteristics or surgical parameters., Methods: We prospectively assessed 280 military members that underwent ACLR. 27 were excluded due to multi-ligamentous injuries or revision surgery, two did not provide informed consent and 62 were lost to follow-up. Patient demographics, pre-injury physical workload, complications and whether/when patients resumed duty and sports were noted, as well as clinical outcomes at a minimum follow-up of one year, including Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee score (IKDC), Lysholm, and Tegner scale., Results: The final cohort of 189 military members (82% men) had mean age of 25.5 ± 3.4 (range,19-38) at ACLR. At 3.3 ± 1.6 years (range, 1.0-6.3), the Tegner score was 6.1 ± 2.0, Lysholm was 87.0 ± 13.7, IKDC was 80.1 ± 15.7, and KOOS was 81.1 ± 14.8. Only 144 patients (76%) resumed duty, at 9.5 ± 5.3 months (range,1-28), and 141 patients (75%) resumed sport, at 10.2 ± 6.2 months (range,1-35). Multivariable analysis revealed that return to duty was less likely in patients with higher BMI (OR,0.89;p = 0.025), but more likely in patients that followed military physiotherapy (OR,2.76;p = 0.017) and with higher pre-injury physical workload (OR,3.93;p = 0.010)., Conclusion: At a follow-up of 3.3 ± 1.6 years, 76% returned to duty at 9.5 ± 5.3 months, and 75% returned to their main sport at 10.2 ± 6.2 months. Patients with higher BMI are significantly less likely to resume military duty and sports; those that followed military physiotherapy were most likely to resume duty, while those that had greater pre-injury physical workload were more likely to both resume duty and sport., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Background: Osteochondral defects of the knee due to trauma or osteochondritis are associated with osteoarthritis in the medium term. Defects 2 to 8cm 2 in size can be managed by autologous matrix-induced chondrogenesis (AMIC®), in which sub-chondral micro-fractures are created within the lesion and the defect is then covered by a matrix of type I and type III collagen to induce de novo cartilage formation. Although promising outcomes have been observed in small single-centre cohorts, the medium-term clinical and radiological effectiveness of AMIC® remains to be demonstrated in larger populations. The objective of this study was to evaluate outcomes of patients at least 2 years after AMIC® for knee osteochondral defects., Hypothesis: AMIC® is associated with clinical and radiological improvements after at least 2 years., Material and Method: This multicentre (16 centres), multisurgeon (18 senior orthopaedic surgeons), retrospective study included consecutive patients who underwent AMIC® with Chondro-Gide® membrane implantation between September 2011 and January 2020. The 36-item Short Form quality-of-life (SF-36) score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) score were determined before the procedure and during follow-up. The Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score was assessed by magnetic resonance imaging 2 years after the procedure., Results: In total, 101 patients aged 12 to 60 years were included. Mean follow-up was 30 months. Mean defect size was 3.44cm 2 (range, 2-8cm 2 ). Significant improvements were documented in the SF-36 score, KOOS, and IKDC score. The mean MOCART score at 2 years was 75% (range, 20-100)., Discussion: The AMIC® procedure was associated with significant improvements at 2.5 years in patients treated for knee osteochondral defects measuring 2 to 8cm 2 . This method seems to provide similar outcomes to those of other available methods with the advantages of single-step surgery and elimination of osteochondral graft donor-site complications., Level of Evidence: IV, retrospective observational cohort study., (Copyright © 2023 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

This paper reports the first case of chronic exertional compartment syndrome in the arm treated surgically. The diagnosis was made in a patient who is under 30 years old, military, and very athletic, with recurrent exertional pain in the anterior compartment of the arms associated with rhabdomyolysis. The high-pressure measurements in the arms' anterior compartment after exertional exercise confirmed the diagnosis. Given the patient's functional demands, a surgical treatment of fasciotomy of the anterior compartment by miniapproach was performed and allowed the resolution of symptomatology with a return to sport at the same level after 3 months., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Two-thirds of ballistic injuries result in severe limb damage. Damage Control Orthopaedic is a surgical strategy that makes it possible to save life, limb and function using simple mnemonic markers: 5minutes, 6hours, 7 days, 8 weeks and 9 months. The many players involved in this coherent care pathway, with its multiple surgical challenges, help to meet the challenge of comprehensive rehabilitation for orthopaedic ballistic injuries., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Introduction: The treatment of osteoarticular infections in Africa is a medical and surgical challenge due to the difficulties in managing antibiotic therapy after the surgical procedure. The objectives of this study were to identify the types of bacteria in osteoarticular lesions in patients treated in Chad and to determine the spectrum of resistance encountered and the efficacy of available antibiotics., Material and Methods: This is a retrospective study of all intraoperative osteoarticular and soft tissue samples taken in a French Role 2 Medical Treatment Facility of N'Djamena during surgery for chronic osteoarticular infections, in Chad, for 1 year., Results: A total of 160 bacterial strains were identified, with a predominance of Gram-negative bacillus (GNB) and staphylococcus infections. Among staphylococci, 80% were methicillin-sensitive streptococci which were generally multidrug-sensitive. Enterococci were resistant to third-generation cephalosporins, first-generation fluoroquinolones and gentamycin. Among GNB, there was a predominance of enterobacteria compared with non-fermenting GNB, of which 52% were multidrug-resistant and produced extended spectrum beta-lactamases (ESBL)., Conclusion: Staphylococcus aureus infections are most often sensitive to available antibiotics and therefore have better prognoses than infections caused by other bacteria. In contrast, in half of the cases of GNB, infections were caused by bacteria producing ESBL, thus posing the problem of multidrug-resistance, the risks of which are increased in precarious situations. Therefore, the type of bacteria appears to be a major prognostic factor in the treatment of osteoarticular infections in a Role 2 in Chad. This criterion will need to be considered before any treatment decisions are made., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Exposure of the coracoid process during arthroscopic stabilization of acute acromioclavicular disjunctions (ACDs) can be achieved either by passing an extra- articular optical portal through the subacromial space or by an intra-articular optical route through the glenohumeral joint with opening of the rotator interval. The objective of our study was to compare the impact on the functional results of these two optical routes. This was a retrospective, multicentre study that included patients operated on for an acute acromioclavicular disjunction arthroscopically. The treatment consisted of surgical stabilization under arthroscopy. The surgical indication was retained for an acromioclavicular disjunction of grade 3, 4 or 5, according to the Rockwood classification. Group 1, which consisted of 10 patients, was operated on with an extra-articular subacromial optical route, and group 2, which consisted of 12 patients, was operated on with an intra-articular optical route with opening of the rotator interval according to the habits of the surgeon. A follow-up of 3 months was performed. The functional results were evaluated for each patient using the Constant score, Quick DASH, and SSV. The delays in returning to professional and sports activities were also noted. A precise postoperative radiological analysis made it possible to analyse the quality of the radiological reduction. No significant difference between the two groups was found between the Constant score (88 vs. 90; p = 0.56), Quick DASH (7 vs. 7; p = 0.58), or SSV (88 vs. 93; p = 0.36). The times to return to work (6.8 weeks vs. 7.0 weeks; p = 0.54) and sports activities (15.6 weeks vs. 19.5 weeks; p = 0.53) were also comparable. The quality of the radiological reduction was satisfactory in the two groups and did not depend on the approach. No clinically or radiologically significant differences between the extra-articular and intra-articular optical portals in the surgical treatment of acute ACDs were found. The optical route can be chosen according to the habits of the surgeon.

The past decade has seen the development of numerous arthroscopic techniques for ankle ligament repair or reconstruction in the treatment of chronic lateral ankle instability. Arthroscopy allows the assessment and treatment of intra-articular pathologies and is associated with faster functional recovery. The open surgery technique described by Blanchet, combining reinsertion of the lateral collateral ligament with reinforcement by an extensor retinaculum flap, has long proven its effectiveness. The aim of this article is to describe this technique under arthroscopy., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Introduction: Each French military orthopedic surgeon is both an orthopedic surgeon and a trauma surgeon. Their mission is to support the armed forces in France and on deployment. The aim of this study was to describe the type of orthopedic surgery performed for the armed forces in France. Our hypothesis was that scheduled surgery was more common than trauma surgery., Methods: We conducted a retrospective descriptive analysis of the surgical activity for military patients in the orthopedic surgery departments of the four French military platform hospitals. All surgical procedures performed during 2020 were collected. We divided the procedures into the following categories: heavy and light trauma, posttraumatic reconstruction surgery, sports surgery, degenerative surgery, and specialized surgery. Our primary endpoint was the number of procedures performed per category., Results: A total of 827 individuals underwent surgery, 91 of whom (11%) were medical returnees from deployment. The surgeries performed for the remaining 736 soldiers present in metropolitan France (89%) consisted of 181 (24.6%) trauma procedures (of which 86.7% were light trauma) and 555 (75.4%) scheduled surgery procedures (of which 60.8% were sports surgery). Among the medical returnees, there were 71 traumatology procedures (78%, of which 87.3% were light traumatology) and 20 procedures corresponding to surgery usually carried out on a scheduled basis (22%, of which 95% were sports surgery)., Conclusion: Military orthopedic surgeons are not just traumatologists; their activity for the armed forces is varied and mainly consists of so-called programmed interventions., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: No therapeutic consensus has been established about proximal ruptures of the rectus femoris muscle. The objective of this literature review is to determine a therapeutic course of action., Methods: We conducted a literature review on the PubMed database using the following keywords (in French and English, respectively): "quadriceps/quadriceps", "droit antérieur/rectus femoris", "proximal/proximal", "chirurgie/surgical", "avulsion/avulsion". We collected 266 articles, 36 of them were selected, which were related to our topic: proximal rupture of the anterior rectus femoris. Patients with a proximal rupture of the rectus femoris, minor or major patient of traumatic origin were included in this study. Patients injured at another lesion level, or non-traumatic lesions of the proximal rectus femoris (tendinitis without ruptures, tumor or others) were excluded. For each patient, the indications, the type of treatment and the functional result were analyzed, with the time to recovery and the level of recovery from sports and professional activities (same sport/profession or not, same level or not) as the main criterion of judgment. Fisher exact test was used for statistical comparison., Results: The aims of conservative treatment are to be pain free for the patient, to fight hematoma and to rehabilitate the injury as quickly as possible. The surgical techniques are varied, with most consisting of either a reinsertion of the musculo-tendon stump or a resection of the scar tissue with myo-tendino-aponeurotic suture in place. The functional results are good for the majority of the treatments proposed, but the conservative treatment has a shorter recovery time (3 months vs. 4 months for the best surgical results). Highly displaced bone avulsion is the only indication for first-line surgical treatment., Conslusion: The main disadvantage of conservative treatment is the risk of residual pain beyond 3 months (10%), justifying an MRI to guide secondary surgical treatment. We propose a treatment plan for proximal rupture of the proximal rectus femoris rupture., (Copyright © 2021 Chinese Medical Association. Production and hosting by Elsevier B.V. All rights reserved.)

Introduction: In this age of social media, with an ever-higher profile for surgery and rankings for the general public, patients' criteria for choosing a surgeon or team are not precisely known, especially in France. We therefore conducted a prospective study concerning anterior cruciate ligament reconstruction: (1) to determine how patients came to know their surgeon; (2) to identify factors affecting final choice., Hypothesis: Patients' choice of surgeon is affected by scores found in social media and rankings found in the press., Material and Method: A prospective continuous study included all patients operated on, without standardization of technique, in 3 hospitals (public and private sector). An anonymous questionnaire on surgeon selection criteria, scored 0 to 10, was distributed on a voluntary basis on the day of surgery scheduling., Results: One hundred and five patients were included. They had come to know of their surgeon via family or friends or their personal physician in more than two-thirds of cases. The essential criterion of final choice was the clarity of the written and oral information provided in consultation (mean score, 8.09±1.83). Other factors included wait-time to surgery (7.39±2.25) and to first consultation (7.26±2.01) and the surgeon's reputation (7.42/10±2.43)., Conclusion: "Word of mouth" and the quality if information provided in consultation motivated final choice, more than any influence of social media or press hospital rankings., Level of Evidence: IV; prospective observational study without control group., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Introduction: Owing to their professional and personal experiences, retired military orthopedic surgeons' views of their careers are a unique source of inspiration. Reflecting on their experiences allows them to grasp the positive points and those that need to be improved for future generations. The purpose of this study is to gather the opinions of retired surgeons on the career of military orthopedic surgeons., Methods: We addressed a questionnaire to all retired French military orthopedic surgeons in the database of the Chair of Applied Surgery for the Armed Forces as of December 2020, retrained in the civilian sector. A questionnaire sent by email made it possible to collect demographic, professional, and personal data about their careers. Subjective data were evaluated using a visual analog scale from 0 to 10 or a subjective qualification scale. The main assessment criterion was the average score (out of 10) of the retired surgeons' opinions on their careers., Results: Fifty-two percent of retired surgeons replied (32 out of 61), with the respondents having an average age of 63 years. They had been in military retirement for an average of 14 years and had practiced for approximately 13.5 years. The majority (28 out of 32) had had a civilian activity after leaving the army. The three main reasons for leaving were the unsatisfactory working environment, the high number of deployments, and insufficient pay. Nevertheless, the respondents were satisfied with their activity, their job, and their training. The average score given for the overall opinion on their careers was 8.14/10. The three main disadvantages of the career that were noted were the quality of family life, the conditions of employment, and the financial aspects. The majority were very satisfied with the second half of their civil career., Conclusion: Overall, the opinion of retired French military orthopedic surgeons on their careers is very good. Their point of view provides interesting elements for reflection from both a professional point of view and a personal point of view. They were very satisfied with the quality of their training, their job, and their activity. However, the quality of their personal/family life, working conditions, and the financial aspects of the career reduced this satisfaction. The results also have potential application in improving the preparation of young military orthopedic surgeons., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: We sought to evaluate the results of the Masquelet-induced membrane technique (IMT) for long bone defect reconstruction within the limited-resource setting of a French forward surgical unit deployed in Chad., Methods: A prospective and observational study was conducted in all patients with a traumatic segmental bone defect in any anatomical location treated by IMT from November 2015 to December 2019. Although IMT was applied by various orthopedic surgeons with variable expertise, all followed the same surgical protocol. Endpoint assessment was performed 12 months after IMT application., Results: Sixteen patients with a mean age of 32.7 years were included in the study. Bone defects were located on the tibia (n = 8), the femur (n = 6) or the radius (n = 2). Thirteen bone defects were infected. After debridement, the mean bone defect length was 4.3 cm. External fixation of the tibia and femur was predominant in both stages. Bone union was achieved in only 8 of the 16 cases at a mean time of 7.6 months. All failures were related to persistent infection or insufficient fixation stability in the second stage., Conclusions: This series is the first to report IMT use in a forward surgical unit. Despite frequent complications, local patients can benefit from this procedure, which is the only available method for bone reconstruction in areas with limited medical resources. A rigorous technical completion at both stages is crucial to limit septic or mechanical failures., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

A rare lesion, limb dislocation, particularly of the foot, is extremely serious. Its initial mortality is related to hemorrhage. Its morbidity is major due to lack of skin coverage of the bones and infection with functional issues. Management remains poorly codified and unknown, and requires a multidisciplinary medical and paramedical team from pre-hospital to rehabilitation. The initial surgery is ideally conservative to control the infection and cover the persistent skin flaps. An unfavorable evolution imposes amputation, sometimes early., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Competing Interests: Les auteurs déclarent n’avoir aucun lien d’intérêts.

Despite all the measures taken preoperatively, bleeding may persist and require surgical control. Before considering treatment, it is necessary to establish the diagnosis with the origin of the bleeding. The surgical procedure depends on the aetiology. There are many surgical options and adjuvant measures to consider. They should be known by the operating theatre nurse, who is a major player in surgical management. Successful control of bleeding requires quality multidisciplinary collaboration., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

The management of pertrochanteric fractures (PTF) in the very elderly relies on early verticalisation to limit complications of the decubitus and this requires stable osteosynthesis allowing immediate full support without risk of mechanical failure. The aim of the study was to analyse the value of cementing the cervicocephalic blade during osteosynthesis with a proximal femoral nail. A prospective bicentric comparative study was con- ducted. Patients over 90 years of age with PTF were included. Centre A used a PFNA (Proximal Femoral Nail Antirotation) nail without blade cementing and Centre B used the same nail with blade cementing. The primary endpoint was the occurrence of disassembly of the osteosynthesis requiring revision surgery. Secondary endpoints were functional out- come (resumption of walking), postoperative pain and duration of surgery. Sixty-four patients were included in Centre A and 23 patients were included in Centre B. Mean age, gender, functional abilities before fracture, fracture type and tip-apex distance were comparable between the groups. Postoperative pain and duration of surgery did not show significant differences between the groups. Four patients operated on with an uncemented PFNA (6.25%) and one patient operated on with a cemented PFNA nail (4.35%) showed early dismantling. The rate of patients returning to walking was significantly higher in the cemented group (p=0.00005). No significant differences in the rate of dismantling were observed between the two groups. However, the group operated on with a cemented PFNA showed better functional recovery with a significantly higher rate of walking recovery.

Introduction: Military surgery requires skills that in general cannot be easily learnt in civilian training. Participation in a fellowship abroad adapted to the particular operating conditions of the foreign deployment is one route that might secure the necessary supplementary training. We therefore assessed the relevance of such a fellowship in the preparedness of young military surgeons in their first deployment., Methods: This study included all active military surgeons who had completed a fellowship abroad during their initial training from 2004 to 2017 in Tchad or Senegal or Djibouti. The collection of data was performed using a questionnaire. The main judgement criterion was the rate of positive answers awarded to the relevance of this fellowship in the preparedness of respondents' first foreign deployment., Results: Sixty-nine of 73 surgeons answered. Sixty-one estimated the fellowship had allowed them to feel more operational during their first mission, with 83.61% rating this feeling as important. Also, 61 recommended the use of a fellowship for war surgery training. The grade assigned to the surgical benefit was 8.48/10., Conclusion: A fellowship abroad permits one to become familiar with surgical practice under austere circumstances and the particularities of the surgical structures at the front. Current trainees' feedback confirms its relevance., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: "Les auteurs déclarent n’avoir aucun lien d’intérêts."

The occurrence of severe limb trauma is a brutal event for all patients in any context. Many questions quickly arise, with a very broad scope - from the course of the intervention to family and social reintegration. The nurse has an essential role in listening, educating and supporting the patient before and after the operation. In addition to reassurance, she plays a central role in organising the return home and helping the patient to resume socio-professional activities., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

The role of the nurse in the emergency reception service has become more complex in recent years in view of the evolution of these services. The particularity of this position lies in its autonomy, adaptation, adjustment, capacity for anticipation and participation in the diagnosis. Illustration of the central role of the nurse in the multidisciplinary care chain of a patient with limb trauma., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

The nurse's role in the management of dressings in limb trauma is essential: conditioning of the patient, correct and complete assessment of the site concerned, before care is provided. She is a privileged partner in planning the follow-up. At each stage, the nurse must be aware of the tasks to be carried out so that the overall management leads to rapid and correct healing., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Limb trauma is a frequent pathology in pre-hospital care. The first responder caregiver plays a crucial role in terms of the application of the initial care in order to save the limb and life of the patient and to limit the functional consequences. He has to follow strict rules of safety and efficiency. The quality of his initial assessment will guide him towards the most appropriate care and the appropriate chronology., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Treatments for a patient with severe limb trauma, require immobilisation in order to stabilise and thus allow bone consolidation or ligament healing or skin protection., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

In the postoperative monitoring of a patient with severe limb trauma, the nurse's objectives are multiple: prevention and screening of complications, follow-up care, compliance with postoperative instructions. Presentation of the key elements of this monitoring, which must be systematised and personalised., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

This study sought foremost to evaluate the outcomes of applying the induced membrane technique (IMT) for tibia reconstruction within the context of a sub-Saharan Africa trauma center. Second, this study aimed to elucidate the conditions of IMT usage in a limited-resource setting. A retrospective study was performed among patients treated via IMT for posttraumatic tibial bone defects who had follow-up data available for at least 12 months. Eleven patients with a mean age of 36 years were included. All presented with an infected multi-tissue defect. The mean length of the tibia defect was 4.4 cm and the mean area of the soft-tissue loss was 32 cm 2 . Pedicled flap coverage was required in all cases. At the mean follow-up time of 15 months bone union was achieved in nine of 11 cases, after additional inter-tibiofibular grafting was performed in four cases. Infection recurrence was noted in five of 11 cases. Most patients presented medium-quality soft-tissue coverage and suboptimal function. IMT may represent a valuable option for tibia reconstruction with limited surgical resources in cases where appropriate infection control and stable soft-tissue coverage can be ensured.

The external fixator is one of the treatments for fractures. It is classically used for serious fractures, polytraumatized patients or when there is a large influx of patients. The resulting paramedical care, which is often unknown, must be rigorous in order to avoid minor and frequent, or serious but less frequent, complications. The stock of what the caregiver must master in this regard: local care, information, monitoring., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: Extension-type supracondylar fractures can be treated with external immobilization, with the elbow flexed 100°. However, this technique requires early evaluation by true lateral x-ray of the elbow to detect secondary fracture displacement., Questions/purpose: The purpose of this work is to evaluate whether ultrasound imaging is suitable for demonstrating initial reduction of supracondylar fractures and early secondary displacement of the fracture., Methods: Fourteen patients aged 3 to 7 years (mean, 4.8 years) were treated by closed reduction under general anesthesia and immobilization with a collar and cuff. All patients had early postoperative x-rays and ultrasonography on day 1, as well as day 8 x-rays and ultrasonography. Ultrasonograms were performed by an experienced senior radiologist., Results: In all cases, a complete reduction was confirmed at initial follow-up on both sonogram and intraoperative fluoroscopy. In 13 of 14 cases, no secondary displacement of the fracture was noted at day 8 on either ultrasonography or x-ray images. In 1 case, a secondary displacement was noted at day 8 on ultrasonography and confirmed by the lateral x-ray., Conclusions: Our study found a complete agreement assessing the quality of intraoperative reduction of supracondylar fractures by radiographs and ultrasonography. These results confirm that ultrasound imaging is suitable for demonstrating secondary displacements of supracondylar fractures in children. We postulate that in Gartland types II and III fractures treated by Blount procedure, a negative ultrasound result at day 8 follow-up may reduce the need for further radiographs. However, in any doubtful situation, the need for conventional radiographs remains., Level of Evidence: Diagnostic study, level II.

During care follow-up, specifically local post-operative care, nurses closely monitor the surgical site both for healing and for local, regional or general risk of infection. In this context, they are on the front line of identifying and reporting any suspicious clinical conditions. We use the example of a patient who presented with textiloma following orthopaedic shoulder surgery., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Mycetoma is a disease that occurs in the mycetoma belt, between latitudes 15̊ south and 30̊ north. It affects disadvantaged regions with limited access to medical and health facilities. Its general principles of care have changed little and are poorly known. We analyzed the management of mycetoma in Chad by French military surgeons deployed within the Epervier and Barkhane operations. This retrospective descriptive study was conducted among the cohort of Chadian patients managed by the N'Djamena forward surgical team from 2007 to 2018 as part of the medical support to the population. It includes 132 patients who had surgery for mycetoma. Surgical parameters of primary treatment and revisions procedures were analyzed. Postoperative follow-up was at least six months. Amputation was performed in 87/132 (66%) patients. Overall 11 (8.3%) required revision surgery, including 7 (5%) with eumycetoma recurrence. All recurrences occurred in the lower limb. The recurrence rate after excision was 10.2% (5/49) versus 2.3% after amputation (2/87). In the absence of effective and accessible medical treatment, surgery remains the basic treatment for mycetoma. Salvage surgery with local excision should always be considered. However, amputation is the only reliable treatment in cases with late presentation. It should not be proposed too early as limb function is preserved for a long time.

Introduction: Intramedullary (IM) nailing is the gold standard for treating long bone fractures in developed countries because of its minimally-invasive application and good biomechanical properties. In precarious conditions, external fixation or open plate fixation are often performed because surgeons do not have the means to carry out IM nailing. However, these procedures can lead to infection-related complications and mechanical failures. The aim of our study was to describe the outcomes and postoperative complications of IM nailing of closed, long bone fractures in patients operated in a French front-line combat surgical unit (role 2+). Our hypothesis was that IM nailing is a reliable technique with low morbidity for the initial treatment of long bone fractures, even in precarious situations., Material and Methods: This was a prospective, single-center, descriptive study of patients operated on between April 2016 and November 2017. All the patients with a closed femur or tibia fracture who were treated by IM nailing were eligible, no matter their time to surgery. The minimum follow-up was 6 months. The primary endpoint was the absence of infection-related complications and the secondary endpoint was fracture union., Results: Fifty-eight patients were reviewed after an average follow-up of 4.7 months (range, 3-15 months). The mean patient age was 35.2 years (15-85 years) and the majority of patients were men (52 of 58). The fracture was in the femur in 74.1% (n=43) of cases and in the tibia in 25.9% (n=15) of cases. The time to surgery averaged 122.3 days (7-720 days) with a median of 60 days. In 74% of cases (n=43), fracture realignment required an open surgical approach. The postoperative course was considered normal in 96.6% of cases (n=51). No infections were reported as of the last follow-up visit. Union occurred in an average of 4 months in 70.7% of cases (n=41). There were three cases of nonunion after 6 months., Discussion: Even in precarious situations, IM nailing is an effective, reliable method with a low complication risk and high union rate for the treatment of neglected long bone fractures. This surgical treatment is well suited to the poor sanitary conditions on the African continent., Level of Evidence: II, low-powered prospective study., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

The prevalence of obesity is increasing. In orthopaedic surgery, the impact of obesity is felt. The aim is to take stock of the consequences of obesity for patients at each stage of management. In this mini-review, we identify the main pathophysiological factors, specific orthopaedic complications and consequences to consider at each stage of management. Obese patients are subjected to a chronic inflammatory state and biomechanical stress. This augments the risk of sepsis and trauma, musculoskeletal damage, the frequency of organ failure and thus, morbidity and mortality. This results in more complex and longer supportive care. At each stage of care, surgeons and doctors have to adapt to optimize care. It is necessary to obtain timely and accurate information from the patient. Patient information is necessary. Being obese in orthopaedics is a factor in poor prognosis. Treatments need to be adapted. This requires specific preparation at each step.

The purpose of this report was to analyze sequential management of patients with combat-related hand injuries in the Kabul International Airport Combat Support Hospital and to identify principles of hand damage control orthopedics (DCO). A retrospective study was conducted using the French Opex data system that included all the patients who received sequential treatment for combat-related hand injuries from 2009 to 2013. Demographics, mechanism, injury pattern, reasons for DCO application and surgical procedures performed during initial and definitive treatment were described. Forty-one patients were included: 14 French soldiers and 27 Afghan patients. Explosive devices were the most common injury mechanism. There were multiple reasons for DCO application in 20 cases. Debridement, skeletal fixation by pinning or splinting, and delayed primary closure were the main emergent procedures. Primary and secondary treatment data did not differ between French and Afghan patients. Although Afghan patients were fully treated on site, the time to secondary procedures was three time higher in this group because of intense operational activity during the period study. The functional outcome was only evaluated in French soldiers who were treated definitely in France. Hand DCO may be required in various situations encountered in both military and civilian settings: polytrauma; delayed transfer to hand specialist; complex high-energy injuries due to firearms or explosive devices. The basic elements of this specific surgical tactic are meticulous debridement, detailed wound assessment and temporary skin coverage., (Copyright © 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Venous thromboembolism (VTE) is a public health problem. Medical repatriation of patients with traumatic lower-limb injuries is common. There are no specific recommendations for the prevention of deep vein thrombosis (DVT). The main objective was to determine the incidence of VTE in this high-risk population and to determine associated risk factors., Materials and Methods: This was a prospective study including patients repatriated to France following lower-limb trauma and hospital discharge. A physical examination and a venous ultrasound were systematically performed on arrival. Reasons for repatriation, methods of VTE prevention and risk factors for VTE were studied. The positive diagnosis of deep venous thrombosis (DVT) was done by Doppler ultrasound., Results: Fifty-two patients with lower-limb trauma were included. Six cases of DVT, four asymptomatic and two symptomatic with pulmonary embolisms were diagnosed. Two patients with asymptomatic DVT did not have preventive anticoagulation. No patient with preventive anticoagulation had symptomatic DVT. Smoking and the absence of preventive anticoagulation were significant risk factors for VTE., Discussion: Repatriation of patients with lower-limb trauma in discharge is associated with an increased risk of VTE. Preventive anticoagulation appears to be effective in preventing DVT. Systematic Doppler imaging can reveal asymptomatic DVT. Our study did not evaluate specifically the interest of venous compression associated to preventive anticoagulation for VTE prevention. Specific recommendations on VTE prevention during repatriation of patients with lower-limb trauma are needed., Conclusion: Preventive anticoagulation should be systematically discussed during repatriation of patients with lower-limb trauma, in the absence of major bleeding risk. Due to the existence of asymptomatic DVT, venous Doppler ultrasound should also be systematically discussed despite the absence of official recommendations., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Morel-Lavallée syndrome is a trauma that remains rare and whose management is not yet standardized. It is a closed delamination between the fascia superficialis and the cutaneous-subcutaneous tissue. This empty space is filled with fluid and may be complicated by surinfection and tissue necrosis. Regularly described in heavy traumatology, it should not be ignored in routine practice. We present the case of a regular leisure athlete with a sus-patellar syndrome of Morel-Lavalée as well as its diagnostic and therapeutic management. The evolution was favorable with a well-conducted conservative treatment. We discuss every step of the possible care in clinical practice to sensitize general practitioners to this pathology.

Foot wounds are frequent and not usually serious. The first caregiver to provide treatment must decide on the most appropriate action to take, sometimes in inadequate places. We present an analysis of the management of these traumas to highlight the key stages of the evaluation and initial treatment of the wound while placing the patient on a coherent and efficient clinical pathway., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Introduction: The damage control orthopedics (DCO) concept is a sequential surgical management strategy indicated when ideal primary treatment is not possible or suitable. DCO principles are routinely applied to hand traumas in wartime practice, but could also be useful in a civilian setting when immediate specialized management cannot be carried out., Methods: The authors report three typical observations of soldiers treated for a complex hand trauma on the field by orthopedic surgeons from the French Military Health Service (FMHS). Application of the hand DCO concept is analyzed and discussed considering the literature and the FMHS experience., Results: With regards to treating the hand, DCO necessitates a meticulous debridement with precise wound assessment, the frequent use of a primary definitive internal fixation by K-wires, and the possibility of a temporary coverage. These simple and fast procedures help avoid infection and prepare the hand for secondary repair., Conclusion: Hand DCO can be applied by any surgeon in various situations: in association with polytrauma, complex injuries requiring multiple reconstructions, or delayed transfer to a specialized center.

Introduction: Injuries to the innominate artery are rare, but potentially fatal. Early diagnosis and treatment may avoid life-threatening complications. Endovascular surgery often has lower morbidity and mortality rates than conventional surgery., Clinical Case: We reported the case of a 28-year-old Yemenite soldier who presented with a shrapnel-related chest puncture wound following a shell explosion in Djibouti causing a 5 mm pseudoaneurysm of the innominate artery without associated complications. After medical repatriation to France, the pseudoaneurysm was treated by endovascular exclusion using a covered stent., Discussion: Endovascular treatment of supra-aortic trunk lesions is an alternative to surgery with fewer postoperative complications, but long-term follow-up is lacking.

Background: Recent conflicts have allowed the French Army Health Service to improve management quality for wartime-injured people during military operations. On November 13, 2015, it was in Paris that France was directly attacked and Bégin Military Teaching Hospital, like several hospitals in Paris, had to face a large number of gunshot victims. Thanks to our operational experience, injured people hospitalized in military hospitals benefited from a management based on triage and damage control (DC) principles., Methods: Forty-five patients were taken care of in our hospital with an average age of 32 years. During triage, eight patients were categorized T1 (with four extreme emergencies) and 10 were classified T2 and 27 as T3. Twenty-two patients underwent emergency surgery, 15 for soft tissue lesions of limbs, 8 for ballistic fractures (one of which was a cervical wound), and 5 for abdominal wounds. Two patients classified T1 died early., Results: In total, more than 50 operations were performed including iterative debridements, bone fixation, three amputations, and two flaps. After 9 months, all of the patients had healed. One woman with limb stiffness required an arthrolysis., Conclusion: This event showed that terrorist attacks and mass casualties with war wounds can occur in France. Acquired experience regarding war wounds by the French Army Health Service is precious. Everyone must understand the importance of triage and the principles of damage control. Every hospital must be ready to face this type of massive influx of injured people (white plan)., Level of Evidence: Epidemiological study, level V.