Switches between biologics in patients with moderate-to-severe psoriasis: results from the French cohort PSOBIOTEQ.

BACKGROUND: Biologics are the cornerstone of treatment of patients with moderate-to-severe plaque psoriasis and switches between biologics are frequently needed to maintain clinical improvement over time. OBJECTIVES: The main purpose of this study was to describe precisely switches between biologics and how their pattern changed over time with the recent availability of new biologic agents. METHODS: We included patients receiving a first biologic agent in the Psobioteq multicenter cohort of adults with moderate-to-severe psoriasis receiving systemic treatment. We described switches between biologics with chronograms, Sankey and Sunburst diagrams, assessed cumulative incidence of first switch by competing risks survival analysis and reasons for switching. We assessed the factors associated with the type of switch (intra-class - i.e. within the same therapeutic class - vs. inter-class) in patients switching from a TNF-alpha inhibitor using multivariate logistic regression. RESULTS: A total of 2153 patients was included. The cumulative incidence of switches from first biologic was 34% at 3 years. Adalimumab and ustekinumab were the most prescribed biologic agents as first and second lines of treatment. The main reason for switching was loss of efficacy (72%), followed by adverse events (11%). Patients receiving a TNF-alpha inhibitor before 2016 mostly switched to ustekinumab, whereas those switching in 2016 or after mostly switched to an IL-17 inhibitor. Patients switching from a first-line TNF-alpha inhibitor before 2016 were more likely to switch to another TNF-alpha inhibitor compared with patients switching since 2018. Patients switching from etanercept were more likely to receive another TNF-alpha inhibitor rather than another therapeutic class of bDMARD compared with patients switching from adalimumab. CONCLUSION: This study described the switching patterns of biologic treatments and showed how they changed over time, due to the availability of the new biologic agents primarily IL-17 inhibitors.

Arthroscopic reconstruction of the lateral ankle ligaments: Radiological evaluation and short-term clinical outcome.

PURPOSE: The purpose of this study was to describe the positioning of bone tunnels of arthroscopic anatomical reconstruction of lateral ankle ligaments (AAR-LAL) and identify radiological measurements associated with short-term clinical outcome one year after surgery. MATERIALS AND METHODS: A total of 61 patients were included in this IRB-approved retrospective study. There were 52 men and 9 women, with a mean age of 36.3 ± 10.8 (SD) years. AAR-LAL was performed to treat chronic instability secondary to strain sequelae after failure of conservative treatment. Good short-term clinical outcome was defined by Karlsson-score≥80 (n=40) one year after surgery. Sixteen radiological measurements were studied to characterize the positionings of fibular, talar and calcaneal tunnels (FT, TT and CT, respectively). Feasibility and inter-observer agreement were calculated for each measurement. Receiver operating characteristic curves were used to identify optimal thresholds for measurements associated with outcome at univariate analysis. A binary logistic regression was used to identify independent predictors. RESULTS: Two measurements were associated with good outcome: distance from the proximal FT entrance to the distal end of the fibula on anteroposterior (AP) view (called 'AP distal FT', P=0.005), and the ratio between the distance from TT entrance to the talo-navicular joint and the talus length on lateral view (P=0.009). Optimal thresholds were of >35mm and<0.445, respectively. At multivariate anlysis, only 'AP distal FT'>35mm remained independent predictor of good outcome (P=0.002). CONCLUSION: Radiological evaluation of bone tunnels following AAR-LAL is feasible, reproducible, and helps predict short-term outcome after reconstruction of lateral ankle ligaments.

Searching for consensus in the approach to patients with chronic lateral ankle instability: ask the expert.

PURPOSE: The purpose of this study is to propose recommendations for the treatment of patients with chronic lateral ankle instability (CAI) based on expert opinions. METHODS: A questionnaire was sent to 32 orthopaedic surgeons with clinical and scientific experience in the treatment of CAI. The questions were related to preoperative imaging, indications and timing of surgery, technical choices, and the influence of patient-related aspects. RESULTS: Thirty of the 32 invited surgeons (94%) responded. Consensus was found on several aspects of treatment. Preoperative MRI was routinely recommended. Surgery was considered in patients with functional ankle instability after 3-6 months of non-surgical treatment. Ligament repair is still the treatment of choice in patients with mechanical instability; however, in patients with generalized laxity or poor ligament quality, lateral ligament reconstruction (with grafting) of both the ATFL and CFL should be considered. CONCLUSIONS: Most surgeons request an MRI during the preoperative planning. There is a trend towards earlier surgical treatment (after failure of non-surgical treatment) in patients with mechanical ligament laxity (compared with functional instability) and in high-level athletes. This study proposes an assessment and a treatment algorithm that may be used as a recommendation in the treatment of patients with CAI. LEVEL OF EVIDENCE: V.

Does antero-lateral ankle impingement exist?

Antero-lateral ankle impingement syndrome (ALAIS) is a well-established clinical entity that is a common consequence of ankle sprains. Injury to the anterior talo-fibular ligament plays a key role in the genesis of ALAIS. Arthroscopic antero-lateral synovectomy is the standard of care. However, this treatment approach may deserve to be challenged, as it does not include any procedure on the ligaments, despite the presence in some patients of lateral rotational micro-instability of the ankle, without objective laxity. Consequently, we reviewed current data on ALAIS and its links to ankle instability, from the dual perspective of diagnosis and treatment.

2016 updated EULAR evidence-based recommendations for the management of gout.

BACKGROUND: New drugs and new evidence concerning the use of established treatments have become available since the publication of the first European League Against Rheumatism (EULAR) recommendations for the management of gout, in 2006. This situation has prompted a systematic review and update of the 2006 recommendations. METHODS: The EULAR task force consisted of 15 rheumatologists, 1 radiologist, 2 general practitioners, 1 research fellow, 2 patients and 3 experts in epidemiology/methodology from 12 European countries. A systematic review of the literature concerning all aspects of gout treatments was performed. Subsequently, recommendations were formulated by use of a Delphi consensus approach. RESULTS: Three overarching principles and 11 key recommendations were generated. For the treatment of flare, colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), oral or intra-articular steroids or a combination are recommended. In patients with frequent flare and contraindications to colchicine, NSAIDs and corticosteroids, an interleukin-1 blocker should be considered. In addition to education and a non-pharmacological management approach, urate-lowering therapy (ULT) should be considered from the first presentation of the disease, and serum uric acid (SUA) levels should be maintained at<6 mg/dL (360 µmol/L) and <5 mg/dL (300 µmol/L) in those with severe gout. Allopurinol is recommended as first-line ULT and its dosage should be adjusted according to renal function. If the SUA target cannot be achieved with allopurinol, then febuxostat, a uricosuric or combining a xanthine oxidase inhibitor with a uricosuric should be considered. For patients with refractory gout, pegloticase is recommended. CONCLUSIONS: These recommendations aim to inform physicians and patients about the non-pharmacological and pharmacological treatments for gout and to provide the best strategies to achieve the predefined urate target to cure the disease.

Arthroscopic anatomical reconstruction of the lateral ankle ligaments.

UNLABELLED: Chronic ankle instability secondary to lateral ligament insufficiency is common after sports injury. Many surgical techniques have been described for the treatment of the lateral ankle ligament complex. They can be classified into repair or reconstruction, and non-anatomical or anatomical. A few authors have recently published innovative techniques for arthroscopic ankle ligament management. This paper describes the arthroscopic techniques enabling anatomical lateral ligament reconstruction using gracilis autograft or allograft for chronic ankle instability. This technique and the steps have been developed by the Ankle Instability Group to make this a reproducible procedure. The purpose of this presentation is to document the technique in the future with a view to a clinical study investigating the results of such surgery in a cohort of suitable patients with chronic ankle instability. LEVEL OF EVIDENCE: V.

Estabilización anterolateral del tobillo por incisión mínima con técnica de hemi-Castaing modificada / Minimal invasive anterolateral ankle stabilization with a modified Hemi-Castaing technique

Antecedentes: Las lesiones de los ligamentos laterales del tobillo son comúnmente observadas en las actividades deportivas. Se encuentran descritas múltiples técnicas para su tratamiento, todas con un último fin: lograr una adecuada estabilidad del tobillo. Las técnicas de invasión mínima y los adelantos tecnológicos en los sistemas de fijación hueso-tendón han venido ganando adeptos en la última década y han impactado también las técnicas de estabilización del tobillo. Material y métodos: Se incluyeron todos los pacientes con diagnóstico de inestabilidad lateral de tobillo que se intervinieron quirúrgicamente y se les realizó un procedimiento de Hemi-Castaing modificado con abordajes mínimos operados en el período de Mayo 2004 a Diciembre del 2007. Tenemos un seguimiento promedio de 30.3 meses. Resultados: Nuestros pacientes presentaron una buena evolución, encontramos una mejoría importante en la escala de Karlsson de 48.7 puntos (± 15.6) a 93.6 puntos (± 9.6). Los pacientes regresaron a su actividad deportiva posterior a la cirugía a los 5.72 meses en promedio (± 4.93). Tenemos una adecuada estabilización corroborada con radiografías dinámicas con sistema Telos. Con una satisfacción personal excelente y buena en 81.9% de los pacientes. Conclusiones: Las modificaciones a la técnica de Hemi-Castaing con el abordaje por incisión mínima, son seguras, reproducibles y nos dan una herramienta más para el tratamiento de esta patología y sobre todo en los casos en donde no se encuentre un adecuado tejido remanente para realizar una reparación anatómica.

Background: The lesions to the lateral ligaments of the ankle are a common sports related injury. There are multiple surgical technics to address the problem all with a common goal: achieve a proper stability of the ankle. The improvements in the minimal invasive technics as well as those in the materials to fixate bone-tissue have also impacted the technics for lateral stabilization of the ankle. Material and methods: We included all the patients with a diagnosis of lateral ankle instability which underwent surgery with a modify Hemi-Casting procedure with minimal invasive approach during the period between May 2004 and December 2007. We have an average follow-up of 30.3 months. Results: Our patients presented a good outcome with an improvement in the Karlsson's scale of 48.7 points (± 15.6) in the preoperative to 93.6 points (± 9.6) during follow-up. They returned to their sports activities after an average of 5.72 months (± 4.93). We used dynamic X-ray's taken with the Telos system and achieved 81.9% of our patients presented an excellent and good personal satisfaction. Conclusions: The modifications to the Hemi-Castaing procedure to perform it with a minimal invasive technic are reproducible and provide us with another tool for the treatment of this pathology specially in the cases where there is no sufficient tissue to perform an anatomical repair.

[Minimal invasive anterolateral ankle stabilization with a modified Hemi-Castaing technique]. / Estabilización anterolateral del tobillo por incisión mínima con técnica de Hemi-Castaing modificada.

BACKGROUND: The lesions to the lateral ligaments of the ankle are a common sports related injury. There are multiple surgical technics to address the problem all with a common goal: achieve a proper stability of the ankle. The improvements in the minimal invasive technics as well as those in the materials to fixate bone-tissue have also impacted the technics for lateral stabilization of the ankle. MATERIAL AND METHODS: We included all the patients with a diagnosis of lateral ankle instability which underwent surgery with a modify Hemi-Casting procedure with minimal invasive approach during the period between May 2004 and December 2007. We have an average follow-up of 30.3 months. RESULTS: Our patients presented a good outcome with an improvement in the Karlsson’s scale of 48.7 points (± 15.6) in the preoperative to 93.6 points (± 9.6) during follow-up. They returned to their sports activities after an average of 5.72 months (± 4.93). We used dynamic X-ray’s taken with the Telos system and achieved 81.9% of our patients presented an excellent and good personal satisfaction. CONCLUSIONS: The modifications to the Hemi-Castaing procedure to perform it with a minimal invasive technic are reproducible and provide us with another tool for the treatment of this pathology specially in the cases where there is no sufficient tissue to perform an anatomical repair.

ANTECEDENTES: Las lesiones de los ligamentos laterales del tobillo son comúnmente observadas en las actividades deportivas. Se encuentran descritas múltiples técnicas para su tratamiento, todas con un último fin: lograr una adecuada estabilidad del tobillo. Las técnicas de invasión mínima y los adelantos tecnológicos en los sistemas de fijación hueso-tendón han venido ganando adeptos en la última década y han impactado también las técnicas de estabilización del tobillo. MATERIAL Y MÉTODOS: Se incluyeron todos los pacientes con diagnóstico de inestabilidad lateral de tobillo que se intervinieron quirúrgicamente y se les realizó un procedimiento de Hemi-Castaing modificado con abordajes mínimos operados en el período de Mayo 2004 a Diciembre del 2007. Tenemos un seguimiento promedio de 30.3 meses. RESULTADOS: Nuestros pacientes presentaron una buena evolución, encontramos una mejoría importante en la escala de Karlsson de 48.7 puntos (± 15.6) a 93.6 puntos (± 9.6). Los pacientes regresaron a su actividad deportiva posterior a la cirugía a los 5.72 meses en promedio (± 4.93). Tenemos una adecuada estabilización corroborada con radiografías dinámicas con sistema Telos. Con una satisfacción personal excelente y buena en 81.9% de los pacientes. CONCLUSIONES: Las modificaciones a la técnica de Hemi-Castaing con el abordaje por incisión mínima, son seguras, reproducibles y nos dan una herramienta más para el tratamiento de esta patología y sobre todo en los casos en donde no se encuentre un adecuado tejido remanente para realizar una reparación anatómica.

Anatomical reconstruction of the anterior talofibular and calcaneofibular ligaments with an all-arthroscopic surgical technique.

Arthroscopy is becoming an essential tool for the treatment of chronic lateral ankle instability. It allows the surgeon to determine which ligaments are injured and choose the most appropriate surgical repair technique, and also to assess and treat any associated injuries. Several arthroscopic techniques for lateral ankle ligament repair have recently been developed. As a consequence, it may be possible to carry out complete lateral ligament reconstruction with an all-arthroscopic procedure. Such an arthroscopic lateral ankle ligament reconstruction technique is described in this article.

Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy.

Ankle sprains are the most common injuries sustained during sports activities. Most ankle sprains recover fully with non-operative treatment but 20-30% develop chronic ankle instability. Predicting which patients who sustain an ankle sprain will develop instability is difficult. This paper summarises a consensus on identifying which patients may require surgery, the optimal surgical intervention along with treatment of concomitant pathology given the evidence available today. It also discusses the role of arthroscopic treatment and the anatomical basis for individual procedures.

The arthroscopic Lapidus procedure.

BACKGROUND: Hypermobility of the first metatarsocuneiform (MC) joint is one of the causes believed to contribute to symptomatic hallux valgus. An arthrodesis of the first MC joint offers definitive correction of the intermetatarsal angle. This procedure can be associated with pseudoarthrosis and shortening of the first ray. This study presents our experience and results with an arthroscopic technique for performing this arthrodesis. MATERIALS AND METHODS: Five patients with severe hallux valgus associated with hypermobility of the first MC joint were treated with this operation. RESULTS: The functional assessment scales revealed very good results. Radiographic evaluation confirmed fusion in all the patients. The hallux valgus angle improved by 25.6°, the intermetatarsal angle improved by 10.6°. The shortening of the first ray was limited to 2.7 mm. CONCLUSION: This new technique is a valid option for performing an arthrodesis of the MC joint.

Can we improve the indication for Bankart arthroscopic repair? A preliminary clinical study using the ISIS score.

The objectives of this study on arthroscopic treatment of chronic anterior shoulder instability were the collection of the current practices for this indication, their development as reported in the literature, and the analysis of preliminary results on a multicenter prospective series of Bankart arthroscopic procedures undertaken using a common technique on patients selected based on the Instability Severity Index Score (ISIS). This procedure predominates in the English-speaking world, whereas the Latarjet protocol is preferred in France. The choice between the two seems to be cultural since neither technique could be demonstrated to be superior in an analysis of 171 responses to an Internet questionnaire in this study. The literature reports disappointing results in the Bankart arthroscopic procedure and recent articles have researched the predictive factors for its failure. Eleven centers prospectively included 125 patients from 1 December 2007 to 30 November 2008. The inclusion criteria were recurrence of anterior instability and an ISIS less than or equal to four points out of 10. All the selected patients underwent capsuloligamentous reinsertion with a common minimal technique of at least three anchors and four sutures with the same postoperative protocol. At a mean follow-up of 18 months, four patients (3.2%) had experienced recurrence. For the 84 patients reexamined at 1 year, the Walch-Duplay and Rowe scores were, respectively, 88.4 and 87.8 points out of 100. Subjectively, 88.1% of the patients declared they were satisfied and would undergo the intervention again. This study confirmed the use of the ISIS as a consultation tool. Only continuation of the study with a minimum follow-up of 3 years will allow us to validate the lower limit of the ISIS below which this technique could be proposed provided that it respects the technical prerequisite of at least four capsuloligamentous sutures.

[Systematic review: value of perioperative chemotherapy in the management of resectable rectal adenocarcinoma (brief report)]. / Synthèse méthodique: intérêt de la chimiothérapie péri-opératoire dans la prise en charge des patients atteints d'un adénocarcinome du rectum résécable d'emblée (rapport abrégé)

UNLABELLED: At the request of the National Thesaurus of Gastrointestinal Cancer (TNCD), the SOR program undertaken by the French federation of cancer centers and now led by the French National Cancer Institute, completed a systematic review to evaluate the value of perioperative chemotherapy in the management of resectable rectal adenocarcinoma in collaboration with clinician experts. METHODS: Results of a systematic literature search using Medline and Embase (from January 1996 to October 2007) were completed by a survey of Evidence- Based Medicine websites. All phase III randomized trials and systematic reviews comparing surgery (alone or associated with adjuvant therapy) to the same treatment plus chemotherapy, or comparing different perioperative chemotherapy modalities in patients with resectable rectal adenocarcinoma, were included in the study. The quality and clinical relevance of the trials were evaluated using validated checklists, allowing to associate each result with its level of evidence. Data synthesis was performed taking into account both efficacy and toxicity outcomes for each intervention. Finally, research recommendations were formulated. RESULTS: Of 29 studies meeting the selection criteria, 19 were included after critical methodological and clinical appraisal. As compared with preoperative radiotherapy, preoperative chemoradiotherapy with 5-fluorouracil and folinic acid does not improve overall or relapse-free survivals but decreases local recurrence rates. Postoperative chemotherapy with 5-fluorouracil and folinic acid does not improve overall or relapse-free survivals, whether the patients received preoperative radiotherapy or preoperative chemoradiotherapy, whereas it seems to decrease local recurrence rates after preoperative radiotherapy but not after preoperative chemoradiotherapy. As compared with postoperative chemoradiotherapy, preoperative chemoradiotherapy with continuous infusion of 5-fluorouracil does not improve overall or relapse-free survivals, but decreases local recurrence rates as well as acute and long-term toxicities. In the absence of preoperative radiotherapy, fluoropyrimidine-based postoperative chemotherapy improves both overall and relapse-free survivals and decreases local recurrence rates. CONCLUSIONS: Preoperative chemoradiotherapy reduces the risk of local recurrence as compared with preoperative radiotherapy or postoperative chemoradiotherapy.

[Arthroscopic repair of full-thickness tears of the rotator cuff.] / Réparation arthroscopique des ruptures transfixiantes de la coiffe.

INTRODUCTION: Shoulder arthroscopy was only at first a surgical technique for subacromial decompression and has been progressively extended to the cuff repairs. This surgery remains nevertheless difficult and requires to be described exactly. A multicenter study of the French Arthroscopic Society allowed to analyse and to underline the quality of the clinical and anatomical results. SURGICAL TECHNIQUE: The technique is described exactly as well as the necessary material. Repair will be adapted to the size and the location of the tear. The technical skill should be simple, effective and reproducible to obtain the best anatomical result. RESULTS: The Constant score improved from an average 46.3 (13.4) to 82.7 (+/-10.3) at the last follow-up, with 62% of patients' symptom free. Strength improved from 5.8 (+/-3.7) to 13.6 (+/-5.4). Ninety-four percent of the results were rated as excellent or good (Constant score>65). A watertight repair was found in 74.1% of the cases. DISCUSSION: Numerous correlations allow to confirm the results found in the literature: the healing of the cuff improves global functional results even when the tear is massive; anatomical result depends on the size of the initial tear; preoperative fatty degeneration is an important predictive factor; the healing of the cuff is related to the age. The quality of the results, the evolution of the material, the simplification and the codification of the surgical technique make it an accessible, effective reproducible surgery.

[Arthroscopic repair of full-thickness tears of the rotator cuff]. / Réparation arthroscopique des ruptures transfixiantes de la coiffe.

INTRODUCTION: Shoulder arthroscopy was only at first a surgical technique for subacromial decompression and has been progressively extended to the cuff repairs. This surgery remains nevertheless difficult and requires to be described exactly. A multicenter study of the French Arthroscopic Society allowed to analyse and to underline the quality of the clinical and anatomical results. SURGICAL TECHNIQUE: The technique is described exactly as well as the necessary material. Repair will be adapted to the size and the location of the tear. The technical skill should be simple, effective and reproducible to obtain the best anatomical result. RESULTS: The Constant score improved from an average 46.3 (13.4) to 82.7 (+/- 10.3) at the last follow-up, with 62% of patients' symptom free. Strength improved from 5.8 (+/- 3.7) to 13.6 (+/- 5.4). Ninety-four percent of the results were rated as excellent or good (Constant score >65). A watertight repair was found in 74.1% of the cases. DISCUSSION: Numerous correlations allow to confirm the results found in the literature: the healing of the cuff improves global functional results even when the tear is massive; anatomical result depends on the size of the initial tear; preoperative fatty degeneration is an important predictive factor; the healing of the cuff is related to the age. The quality of the results, the evolution of the material, the simplification and the codification of the surgical technique make it an accessible, effective reproducible surgery.

[Arthroscopic repair of full-thickness cuff tears: a multicentric retrospective study of 576 cases with anatomical assessment]. / Réparation arthroscopique des ruptures transfixiantes de la coiffe des rotateurs: étude rétrospective multicentrique de 576 cas avec contrôle de la cicatrisation.

PURPOSE OF THE STUDY: Totally arthroscopic repair of rotator cuff tears is now common practice. The techniques used were evaluated by a retrospective multicentric analysis conducted by the French Society of Arthroscopy. MATERIAL AND METHODS: The series was limited to arthroscopic repair of full thickness tears of the supraspinatus or infraspinatus evaluated using the Constant score and arthro-MRI or arthroscan performed with at least one year follow-up. Data were processed with SPSS 10. The series included 576 patients who underwent surgery between January 2001 and June 2003. Mean patient age was 57.7 years; 52% were men and 60% were manual laborers. The mean preoperative Constant score was 46.4 +/- 13.4/100. The tear was limited to the supraspinatus in 69% of shoulders, with extension to the upper third of the infraspinatus in 23.5% and the entire infraspinatus in 7.5%. The supraspinatus tear was distal in 41.7% of shoulders, intermediary in 44% and retracted in 14.3%. Fatty degeneration of the supraspinatus was noted grade 0 in 60%, 1 in 27%, 2 in 11% and 3 in 2%. Arthroscopic repair was performed in all cases, with locoregional anesthesia in 60.9%. Bioresorbable implants were used in 33% and metallic implants in 62.1%. Acromioplasty was performed in 92.7% and capsulotomy in 14.9%. RESULTS: On average, the subjective outcome was scored 8.89/10. The Constant score improved from 46.3 +/- 13.4 to 82.7 +/- 10.3 with 62% having a strictly pain free shoulder. Muscle force improved from 5.8 +/- 3.7 to 13.6 +/- 5.4. Outcome was excellent in 94% of shoulders at 18.5 months mean follow-up. The complication rate in this series was 6.2% with 3.1% prolonged stiffness, 2.7% reflex dystrophy, 0.2% infection, and 0.2% anchor migration. The cuff was considered normal in 55.7% of shoulders with an intratendon addition image in 19%, i.e. 74.7% of non-ruptured cuffs. Minimal loss of integrity was noted in 9.5% and was marked in 15.7%, i.e. 25.2% iterative tears.ANATOMOCLINICAL CORRELATIONS: The Constant score was strongly correlated with rotator cuff integrity (p<0001). This correlation was also found for force (p<0001), motion (0.01) and activity (0.04), but not for pain. The clinical outcome was correlated with extension, retraction, intrasubstance tear, and fatty degeneration of the lesion preoperatively. Anatomic results were statistically less favorable for tears which were older, extensive, retracted or associated with fatty degeneration. Age was correlated with extent of the initial tear and also with less favorable anatomic and clinical outcome. Occupational accidents were correlated with less favorable clinical outcome. CONCLUSION: Functional improvement after healing is a strong argument for repair. Arthroscopy has the advantage of combining a low complication rate with good clinical and anatomic results. Age is correlated with functional outcome and healing, but is not a contraindication.

[Bipolar arthroplasty in rotator cuff arthropathy: 13 cases]. / Résultats de l'arthroplastie intermédiaire dans le traitement de l'omarthrose excentrée.

PURPOSE OF THE STUDY: A series of 13 patients with an excentered osteoarthritis of the glenoid who underwent bipolar shoulder arthroplasty is reported. MATERIAL AND METHODS: The series included 13 patients treated in two centers between 1995 and 1998. Mean age was 70 years (58-88). Constant's absolute score and Swanson's score were used for clinical assessment. The Hamada and Fukuda classification was used for the radiographic assessment. The follow-up radiography series included an AP view in the three rotation positions, an AP view in maximum abduction to assess intraprosthetic mobility, a lateral view (Lamy) and measurements of both humeri. Several measurements were made to assess humerus lateralization and glenoid wear: deltoid lever arm, lateral humeral displacement, distance between the lateral border of the coracoid and the center of the glenoid and the subacromial space. Mean preoperative Constant score was 23 points: pain 3 pts, activity 5 pts, motion 13 pts, force 2 pts. Mean preoperative Swanson score was 11. Active anteflexion was 78 degrees, active abduction 68 degrees and passive external rotation 17 degrees. The Hamada and Fukuda classification was 9 grade 4 and 4 grade 5. All patients had a full thickness unrepairable rotator cuff tear: three with 2 tendon tears, and 10 with 3 tendon tears. All patients were reviewed clinically and had a complete radiography series at last follow-up (mean 28 months, range 7 - 56 months). RESULTS: At last follow-up, the mean absolute Constant score was 37 points: pain 10 pts, activity 9 pts, motion 14 pts, force 4 pts. Mean Swanson score at last follow-up was 19 points. Mean active anteflexion was 69 degrees, active abduction was 63 degrees and passive external rotation was 29 degrees. A satisfactory deltoid lever arm had been achieved compensating the glenoid wear by a greater lateral displacement of the humerus. At last follow-up, there were no cases of humeral loosening but three cases with important glenoid wear were observed after two years. Comparing the results obtained using small cups (40 and 44) with arthroplasties using large cups (48 and 52) showed a trend favoring small cups: Constant score 43 vs 32 points, Swanson score 21 versus 17 points, anteflexion 72 degrees versus 66 degrees and passive external rotation 34 degrees versus 26 degrees. DISCUSSION: Our results confirmed the efficacy of bipolar arthroplasty for pain relief, but the mobility outcome was less than satisfactory, excepting passive external rotation. It would appear to be preferable to use small cups. Comparing our results with data in the literature, particularly the better results for mobility using simple humeral prostheses, suggests that the principles of shoulder and hip arthroplasty concern different mechanisms: a sufficient deltoid lever arm must be achieved, but without overstretching the periarticular soft tissue (capsule, subcapsule, teres minor), and using a cup size close to the size of the healthy humeral head. Glenoid reaming should not be reserved only for asymmetrical glenoid wear in the horizontal plane. CONCLUSION: Our results suggest that bipolar arthroplasty for excentered osteoarthritis of the glenoid cavity is indicated for: stiffness in external rotation, major concentric wear in patients under 65 years of age, or asymmetric glenoid wear.

Treatment strategies for metastatic Ewing's sarcoma.

Therapy in metastatic Ewing's sarcoma is reviewed using the methodology recommended by the guidelines project of the Federation of French Cancer Centres (FNCLCC) Standards, Options and Recommendation (SOR) Group. Twelve articles relating to conventional dose therapy and seven articles related to high-dose therapy were judged suitable for detailed appraisal. Rates of complete response (CR) at metastatic sites and local control were high using combinations of vincristine, actinomycin, cyclophosphamide and doxorubicin with radiation or surgery. With more recent regimens, including increased doses of alkylating agents and anthracyclines the relapse-free survival has increased from <15 to 20-30%. 'Megatherapy' regimens with haematopoietic stem cell rescue are tolerable in this patient group, but to date there is little evidence of any benefit. It appears that patients with isolated lung metastases do significantly better (approximately 40% EFS) than those presenting with combined sites such as bone, bone marrow and lung. The use of lung irradiation in children with lung metastases is associated with a reduced incidence of subsequent lung recurrence and a consistently better overall relapse-free survival (RFS).