Do number of days with low back pain and patterns of episodes of pain have similar outcomes in a biopsychosocial prediction model?

PURPOSES: We used two different methods to classify low back pain (LBP) in the general population (1) to assess the overlapping of individuals within the different subgroups in those two classifications, (2) to explore if the associations between LBP and some selected bio-psychosocial factors are similar, regardless which of the two classifications is used. METHOD: During 1 year, 49- or 50-year-old people from the Danish general population were sent fortnightly automated text messages (SMS-Track) asking them if they had any LBP in the past fortnight. Responses for the whole year were then classified into two different ways: (1) In relation to the number of days with LBP in the preceding year (0, 1-30, and >30), (2) In relation to the frequency and duration of episodes of LBP (more or less never pain, episodic, and more or less constant pain). Some bio-psychosocial factors, collected with a questionnaire at baseline 9 years earlier, were entered into regression models to investigate their associations with the subgroups of the two classifications of LBP and the results compared. RESULTS: The percentage of agreement between categories of the two classification systems was above 68 % (Kappa 0.7). Despite the large overlap of persons in the two classification groups, the patterns of associations with the two types of LBP definitions were different in the two classification groups. However, none of the estimates were significantly different when the variables were compared across the two classifications. CONCLUSION: Different classification systems of LBP are capable of bringing forth different findings. This may help explain the lack of consistency between studies on risk factors of LBP.

Time-course of prednisone effects on hormonal and inflammatory responses at rest and during resistance exercise.

Glucocorticoids are among the most commonly used drugs. They are widely administered for acute and chronic musculoskeletal pain, as well as for several other pain syndromes, although their therapeutic use is sometimes diverted for doping purposes. Their time-course effects on hormonal and inflammatory responses nevertheless remain poorly understood, both at rest and during exercise. We therefore studied the alterations induced by 1 week of prednisone treatment (60 mg daily) in recreationally trained male athletes after 2 days (i. e., acute) and 7 days (i. e., short-term). Hormonal (i. e., DHEA, DHEA-S, aldosterone, and testosterone) and pro- and anti-inflammatory markers (i. e., IL-6, IL-10, and IL-1ß) were investigated at rest and after resistance exercise. A significant decrease in DHEA and DHEA-S (p<0.01) without change in the DHEA/DHEA-S ratio, aldosterone, or testosterone was demonstrated after acute prednisone intake. A significant increment in IL-10 and a significant decrement in IL-6 (p<0.05) were also observed with prednisone both at rest and during exercise, without significant change in IL-1ß. Continued prednisone treatment led to another significant decrease in both DHEA and DHEA-S (p<0.05), whereas no change in the inflammatory markers was observed between days 2 and 7. Our data demonstrate that the anti-inflammatory effects of prednisone were maximal and stable from the beginning of treatment, both in rest and exercise conditions. However, hormonal concentrations continued to decline during short-term intake. Further studies are needed to determine the effects of hormonal time-course alterations with longer glucocorticoid treatment and the clinical consequences.

The diurnal patterns of cortisol and dehydroepiandrosterone in relation to intense aerobic exercise in recreationally trained soccer players.

Diurnal patterns of cortisol and dehydroepiandrosterone (DHEA) secretion, the two main peripheral secretory products of the hypothalamic-pituitary-adrenal neuroendocrine stress axis, have been well characterized in rest conditions but not in relation to physical exercise. The purpose of this investigation was therefore to determine the effects of an intense 90-min aerobic exercise on the waking diurnal cortisol and DHEA cycles on three separate days [without exercise, with morning exercise (10:00-11:30 h), and with afternoon exercise (14:00-15:30 h)] in nine recreationally trained soccer players. Saliva samples were collected at awakening, 30 min after awakening, and then every 2 h from 08:00 to 22:00 h. A burst of secretory activity was found for cortisol (p < 0.01) but not for DHEA after awakening. Overall, diurnal decline for both adrenal steroids was observed on resting and exercise days under all conditions. However, there was a significant increase in salivary cortisol concentrations on the morning-exercise and afternoon-exercise days at, respectively, 12:00 h (p < 0.05) and 16:00 h (p < 0.01), versus the other trials. This acute response to exercise was not evident for DHEA. The results of this investigation indicate that 90 min of intense aerobic exercise does not affect the circadian pattern of salivary adrenal steroids in recreationally trained athletes over a 16-h waking period, despite a transitory increase in post-exercise cortisol concentration. Further studies are necessary to determine whether these results are applicable to elite athletes or patients with cortisol or DHEA deficiency.

Bone texture analysis of human femurs using a new device (BMA™) improves failure load prediction.

UNLABELLED: We measured bone texture parameters of excised human femurs with a new device (BMA™). We also measured bone mineral density by DXA and investigated the performance of these parameters in the prediction of failure load. Our results suggest that bone texture parameters improve failure load prediction when added to bone mineral density. INTRODUCTION: Bone mineral density (BMD) is a strong determinant of bone strength. However, nearly half of the fractures occur in patients with BMD which does not reach the osteoporotic threshold. In order to assess fracture risk properly, other factors are important to be taken into account such as clinical risk factors as well as macro- and microarchitecture of bone. Bone microarchitecture is usually assessed by high-resolution QCT, but this cannot be applied in routine clinical settings due to irradiation, cost and availability concerns. Texture analysis of bone has shown to be correlated to bone strength. METHODS: We used a new device to get digitized X-rays of 12 excised human femurs in order to measure bone texture parameters in three different regions of interest (ROIs). We investigated the performance of these parameters in the prediction of the failure load using biomechanical tests. Texture parameters measured were the fractal dimension (Hmean), the co-occurrence matrix, and the run length matrix. We also measured bone mineral density by DXA in the same ROIs as well as in standard DXA hip regions. RESULTS: The Spearman correlation coefficient between BMD and texture parameters measured in the same ROIs ranged from -0.05 (nonsignificant (NS)) to 0.57 (p = 0.003). There was no correlation between Hmean and co-occurrence matrix nor Hmean and run length matrix in the same ROI (r = -0.04 to 0.52, NS). Co-occurrence matrix and run length matrix in the same ROI were highly correlated (r = 0.90 to 0.99, p < 0.0001). Univariate analysis with the failure load revealed significant correlation only with BMD results, not texture parameters. Multiple regression analysis showed that the best predictors of failure load were BMD, Hmean, and run length matrix at the femoral neck, as well as age and sex, with an adjusted r (2) = 0.88. Added to femoral neck BMD, Hmean and run length matrix at the femoral neck (without the effect of age and sex) improved failure load prediction (compared to femoral neck BMD alone) from adjusted r (2) = 0.67 to adjusted r (2) = 0.84. CONCLUSION: Our results suggest that bone texture measurement improves failure load prediction when added to BMD.

Reproducibility of kinematic motion coupling parameters during manual upper cervical axial rotation mobilization: a 3-dimensional in vitro study of the atlanto-axial joint.

INTRODUCTION: The reproducibility of the 3-dimensional (3D) kinematic aspects of motion coupling patterns of segmental manual mobilizing techniques is not yet known. This study analyzes the segmental 3D aspects of manual mobilization of the atlanto-axial joint in vitro. METHODS AND MATERIALS: Twenty fresh human cervical specimens were studied in a test-retest situation with two examiners. The specimens were manually mobilized using three different techniques: a regional mobilization technique, a segmental mobilization technique on the atlas with manual fixation of the axis and a segmental mobilization applying a locking technique. Segmental kinematics were registered with a Zebris CMS20 ultrasound-based tracking system. The 3D aspects of motion coupling between main axial rotation and coupled lateral bending were analyzed by six parameters: the range of motion the three motion components, the cross-correlation, the ratio and the shift. RESULTS: The results indicate stronger intra- than inter-examiner reproducibility. The range of motion of the axial rotation component shows a substantial level of intra- and inter-examiner reproducibility (ICC's 0.67-0.76). The parameters describing the coupling patterns show only moderate to substantial intra-examiner reproducibility for the more experienced of the two examiners (ICC's 0.55-0.68). All other correlations were not significant and no differences could be observed between regional versus segmental techniques. CONCLUSION: Reproducibility of segmental 3D-aspects of manual mobilization of the atlanto-axial joint in an in vitro situation can differ between examiners. The results of the present study may indicate a possible tendency to higher reproducibility if mobilizations are performed by an examiner with high expertise and experience in applying the specific techniques. Continued investigation including more examiners with different levels of experience and different techniques is necessary to confirm these observations.

[Two key describers of the sacro-acetabular relationships: the angles of sacral and acetabular incidence]. / Deux descripteurs clé des relations sacro-cotyloïdiennes : les angles d'incidence sacrée et cotyloïde Mise en évidence par le logiciel De-Visu.

PURPOSE OF THE STUDY: Implantation of total hip arthroplasties raises several important questions concerning the relationship between the orientation of the lumbosacral joint and the acetabular-femoral joint; in other words, between the position of the patients trunk and the orientation of the acetabula. To elucidate better these complex relationships, we conducted a morphometry study on a sample of 51 dry pelves: pelv 26 female and 25 male specimens. MATERIAL AND METHODS: Three-dimensional coordinates of 47 homologous points were recorded for each pelvis. Data were then processed with De-Visu, a graphic visualization software. Seven parameters were compared: sacral slope, sacral incidence, and five parameters quantifying the three-dimensional orientation of the acetabula. RESULTS: The graphic modelization enabled an integral 3-D visualization of each pelvis. The sagittal view enabled simultaneous visualization of the sacrum, the sacroiliac joints, the acetabula, and their alignments, as well as the variability of their spatial relation. The position reference chosen to simulate the upright position aligned the anterior iliac spines and the superior pubic point. This position was found pertinent because the mean value of the sacral slope (41.8) and the sacral incidence (54) were not different from published series. The sacral slope was the most strongly correlated with the acetabular parameters. It exhibited a positive correlation with sagittal acetabular slope (r=0.59) and acetabular inclination (r=0.59). It exhibited a negative correlation with acetabular anteversion (R=0.45). The correlation with the sagittal acetabular slope was very strong for anteversion (r=0.92), and rose with acetabular inclination (r=-0.66). The angle formed by the two acetabular axes was highly variable (37). The correlation between this angle and inclination was very high in males (r=-0.88) and non-significant in females. There was however a very strong correlation with anteversion in females (r=-0.74) which was non-significant in males. This contrasting finding was related to the wide spread of the inclination values in males and anteversion values in females. DISCUSSION: We demonstrated a new sagittal parameter: the acetabular incidence. The summit of this angle is the center of the acetabulum. The sides are the pelvic thickness and the acetabular axes. This parameter was negatively correlated with the sacral incidence. It account simultaneously for the sagittal position of the sacrum in relation to the acetabula and for the degree of acetabular anteversion and inclination. We have demonstrated that the geometric sum of these two angles, sacral incidence and acetabular incidence, is equivalent to the sacro-acetabular angle demonstrated by Lazennec and Saillant. These authors showed that the sacro-acetabular angle is the sum of two positional parameters, the sacral slope and the sagittal acetabular tilt (or slope). The three angles -- sacral incidence, acetabular incidence, sacro-acetabular angle -- are anatomic angles which do not vary with the pelvic position.

[Femoral neck fractures in patients over 50 years old]. / Les fractures du col du fémur après 50 ans.

INTRODUCTION: Despite many papers and instructional course lectures, therapeutic guidelines are not clearly defined about treatment of femoral neck fractures. The aim of this multicentric French symposium was to prospectively study the results of current therapeutic options in order to propose scientifically proven options. MATERIAL AND METHODS: Three prospective studies were carried out in order to answer to these questions: (1) is it possible with anatomical reduction and stable fixation to lower the non union and osteonecrosis rate? (2) is functional treatment of Garden 1 fractures successful in more than 65 years patients? (3) what criteria are useful to choose the kind of arthroplasty for more than 65 years patients? RESULTS: For the 64 patients between 50 and 65 years old included in the first study, 44 ORIF and 17 prostheses were performed. No open reduction was performed in this series despite a 34% malreduction rate. The risk for displacement after functional treatment of Garden 1 fractures is 31%. For patients over 65 years old, almost fractures are treated in this series by an arthroplasty. The one-year mortality rate after displaced femoral neck fracture was 17%. Functional results were better in total hip prosthesis group than in bipolar or unipolar group. Non cemented stems were not safer than cemented ones in frail patients. DISCUSSION AND CONCLUSIONS: For young patients, ORIF should be the treatment of choice: the initial displacement and its effects on the femoral head vascularisation, the quality of reduction and fixation are the two most significant factors for good outcome. For Garden 1, fractures in patients 65 years old or more, it is proposed to performed an internal fixation despite in two thirds of the cases, it should be unnecessary because non identification of predictive factors of failure. For patients over 65 years old, the type of arthroplasty to perform in displaced fractures is to be chosen according to the preoperative mobility and comorbidities. Because of acetabular erosion with long-term follow-up, it is clearly indicated to perform total hip replacement for patients with life expectancy of 10 years or more. For frail patients, unipolar arthroplasty is the best option. The place for bipolar or uncemented implants is not yet well-defined and more prospective trials are needed. In this multicentric study, results appear quite different in terms of mortality, or functional status. These differences seem to be related to technical choice, geriatric care, nutritional consideration or surgical organisation, all factors that may be of major importance for prognostic.

Neuroendocrine and inflammatory responses to DHEA administration in young healthy women.

DHEA is reported to have beneficial effects for the elderly and for several pathologies because of its behavioral and anti-inflammatory properties. However, these properties have never been investigated in a young healthy population. The purpose of this double-blind, randomized study was therefore to investigate the effects of short-term DHEA administration (100 mg/day/4 weeks) on neuroendocrine (i.e., beta-endorphin and prolactin) and inflammatory (i.e., interleukin-6 and TNF-alpha) parameters in 10 young healthy female volunteers with regular sports practice. In parallel, the stress state was assessed with the Profile of Mood States (POMS) questionnaire. DHEA administration did not alter prolactin, interleukin-6 or TNF-alpha, and no significant change in tension, depression, anger, vigor, fatigue or confusion was noted. However, beta-endorphin levels increased significantly (p < 0.05) with the DHEA treatment. The results of this investigation indicate that short-term DHEA administration improves neuroendocrine modulation but does not affect the inflammatory status or psychological state in recreationally trained female athletes. Further studies are needed to determine the exact mechanisms and the responses of these parameters to DHEA administration at higher dosages and/or for longer durations, especially in response to physical/psychological stress.

Tendinous muscular insertions onto the deep fascia of the upper limb. First part: anatomical study.

We examined 30 upper limbs in order to study the tendinous muscular insertions into the deep fascia and to verify whether they have a specific anatomical arrangement and to measure their resilience to traction. We have found that the fascia receives many tendinous muscular insertions, which are always present and exhibit a constant anatomical structure. In particular, the pectoralis major fascia always continues with the brachial fascia in two distinct ways: the fascia overlying the clavicular part of pectoralis major had an expansion towards the anterior brachial fascia, whereas the fascia covering its costal part extended into the medial brachial fascia and the medial intermuscular septum. The lacertus fibrosus was also composed by two groups of fibres: the main group was oriented downwards and medially, the second group longitudinally. The palmaris longus opened out into a fan-shape in the palm of the hand and sent some tendinous expansions to the flexor retinaculum and fascia overlying the thenar eminence muscles. In the posterior region of the arm, the fascia of the latissimus dorsi sent a fibrous lamina to the triceps brachial fascia. The triceps tendon inserted partially into the antebrachial fascia, while the extensor carpi ulnaris sent a tendinous expansion to the fascia of the hypothenar eminence. It is hypothesized that the tendinous muscular insertions maintain the fascia at a basal tension and create myofascial continuity between the different muscles actuating flexion and extension of the upper limb, stretching the fascia in different ways according to the different motor directions.

Anatomy of the deep fascia of the upper limb. Second part: study of innervation.

Analysis of specimens taken from different areas of the deep fascia in 20 upper limbs was made in order to establish which kind of nerve fibres and endings are present in the deep muscular fascia. The flexor retinaculum and the lacertus fibrosus were also evaluated because they are anatomically hardly separable from the deep muscular fascia, although they have different functions. In particular, specimens were taken at the level of: (a) the expansion of pectoralis major onto the bicipital fascia, (b) the middle third of the brachial fascia, (c) the lacertus fibrosus, (d) the middle third of the antebrachial fascia, (e) the flexor retinaculum. This study demonstrated an abundant innervation of the fascia consisting in both free nerve endings and encapsulated receptors, in particular, Ruffini and Pacini corpuscles. However, differences in innervation were verified: the flexor retinaculum was resulted the more innervated element whilst lacertus fibrosus and the pectoralis major expansion the less innervated. These results suggest that the retinaculum has more a perceptive function whereas the tendinous expansions onto the fascia have mostly a mechanical role in the transmission of tension. The hypothesis that the fascia plays an important role in proprioception, especially dynamic proprioception, is therefore advanced. In fact, the fascia is a membrane that extends throughout the whole body and numerous muscular expansions maintain it in a basal tension. During a muscular contraction these expansions could also transmit the effect of the stretch to a specific area of the fascia, stimulating the proprioceptors in that area.

Influence of glenohumeral mismatch on bone strains and implant displacements in implanted glenoïds. An in vitro experimental study on cadaveric scapulae.

In shoulder arthroplasty, there is no consensus about the ideal mismatch between a prosthetic humeral head and a glenoïd component. Thus, investigations into mismatch effects from a biomechanical point of view can be useful. The aim of this in vitro study was to help us understand mismatch influence on bone strains, translational forces in the joint and implant/bone displacements in implanted scapulae. Five fresh cadaveric scapulae were implanted with a cemented keeled polyethylene implant. The lower part of the scapulae was embedded and the loadings were carried out using five metallic spheres simulating mismatches of 0, 2, 4, 5 and 6 mm. Loadings included a constant compressive preload of 392N and an anterior, posterior, inferior and superior translation of 2.5 mm. We measured the transversal force necessary to produce the imposed translation, the strains at six locations around the peripheral cortex of the glenoïd using strain gages and the relative implant/bone displacements using CCD cameras. Generally, the increase of mismatch reduced the translational forces, the strains around the glenoïd and, except for the anterior loading, the relative implant/bone displacements. Few and even no significant differences were observed when the mismatch varied from 0 to 2 mm; the number of significant differences increased when the mismatch varied from 0 to 4mm and from 0 to 5 mm; the results obtained for a 0-6 mm variation in mismatch were comparable to those obtained for a 0-5 mm variation. This study underlines that the mismatch has a significant effect on bone strains, relative implant/bone displacements and induced translational forces when a compressive preload and imposed translations were applied on implanted scapulae.

Comparative gait initiation kinematics between simulated unilateral and bilateral ankle hypomobility: Does bilateral constraint improve speed performance?

Improvement of motor performance in unilateral upper limb motor disability has been shown when utilizing inter-limb coupling strategies during physical rehabilitation. This suggests that 'default' bilateral central motor commands are facilitated. Here, we tested whether this bilateral motor control principle may be generalized to the lower limbs during gait initiation, which involves alternate bilateral actions. Disability was simulated by strapping to produce ankle hypomobility. Healthy adult subjects initiated gait at a self-paced speed with no ankle constraint (control), or with the stance, swing or bilateral ankles strapped. The duration of the anticipatory postural adjustments lengthened and the center of mass instantaneous progression velocity at foot-off decreased when the ankle was strapped. During the step execution phase, progression velocity at foot-contact was higher when both ankles were strapped compared to unilateral strapping of the stance ankle. These findings suggest that bilateral central motor commands are favored during walking tasks. Indeed, unilateral constraint of the stance ankle should compel the central nervous system to adapt specific commands to the constraint and normal sides whereas the 'default' bilateral motor commands would be utilized when both ankles are strapped leading to better kinematics performance. Bilateral in-phase upper limb coordination and bilateral alternating lower limb locomotor movements may share similar control mechanisms.

Effect of oral glucocorticoid intake on autonomic cardiovascular control.

This study analyzed baroreflex sensitivity, heart rate and systolic blood pressure variabilities during an oral 1 week administration of prednisone. This study examined the hypothesis that prednisone might change both systolic blood pressure level and baroreflex sensitivity. Twelve physically active male subjects participated to a double-blind, randomized cross-over study consisting of two 1-week periods of treatment separated by a 4-week drug-free washout period: placebo (PLA) or prednisone (PRED). Trials were performed by each subject four times on the second (D2) and seventh (D7) day of each treatment period. ECG and blood pressure were continuously recorded to compute heart rate variability, systolic blood pressure variability and baroreflex sensitivity components with the smoothed pseudo Wigner Ville distribution and baroreflex analysis. Following D2 prednisone treatment, both HR (PLA: 60.8 ± 10.5 vs. PRED: 65.8 ± 9.1 beats min(-1), p = 0.008) and low frequency component of systolic blood pressure variability (D2: 3.09 ± 0.19 vs. D7: 2.34 ± 0.19, p < 0.041) increased whereas other components did not change. Over 7 days of treatment, LF-SBP amplitude increased (D2: 2.71 ± 0.89 vs. D7: 3.87 ± 0.6 mmHg, p = 0.037). A slight increase in both HR and LF-SBPV were observed suggesting a potential sympathetic cardiovascular stimulus. Although we found a significant effect of the 1-week prednisone treatment on heart rate and low frequency power of systolic blood pressure variability, we reported neither an increase in the systolic blood pressure level nor a decrease in the baroreflex sensitivity. Therefore, the fragility of our results cannot support a deleterious effect of 1-week administration of prednisone on the autonomic cardiovascular control which might be involved in cardiovascular diseases.

The hyperabduction test.

We studied 100 fresh human shoulders in cadavers (mean age 76 years), and the range of passive abduction (RPA) in 100 volunteers with normal shoulders and in 90 patients with instability of the joint, over a period of six years. The anatomical and clinical findings showed that passive abduction occurs within the glenohumeral joint only, is controlled by the inferior glenohumeral ligament and has a constant value in 95% of both shoulders in normal subjects. In patients with instability, 85% showed an RPA of over 105 degrees with 90 degrees in the contralateral shoulder. In the remaining patients a strongly positive apprehension test suggested a diagnosis of instability. An RPA of more than 105 degrees is associated with lengthening and laxity of the inferior glenohumeral ligament.

Axon regeneration and vascularisation of nerve grafts. An experimental study.

An experimental model has been designed to assess the effect of vascularisation on axon regeneration in nerve grafts. The vascular status of the grafts has been demonstrated by microangiography and histology. Rat sciatic nerve grafts in which the vascular pedicles were left intact retained a normal vascular pattern which was not adversely affected by wrapping the graft in a polythene sleeve. In devascularised grafts, revascularisation commenced at three days and was complete at nine days. If the devascularised grafts were wrapped in a polythene sleeve, revascularisation was impeded and at fifteen days the middle segment of the graft was avascular and infarcted. The rate of axon regeneration was measured electrophysiologically in the above four groups of nerve grafts. There was a linear relationship between the rate of axon regeneration with time post-graft, axon growth proceeding at a mean rate of 1.150mm/day (S.E. +/- 0.084) after a mean delay of 4.85 days. There was no significant difference in the rate of axon regeneration in the four groups.

[MRI in the pre-operative evaluation of lesions of the rotator cuff]. / Apport de l'IRM dans le bilan pré-chirurgical des lésions de la coiffe des rotateurs.

The authors report a series of 38 patients who had been examined by MRI and then operated for a rotator cuff syndrome. The correlation between the description of the cuff lesions after MRI and the surgical observations were excellent for 37 patients. In one case MRI showed a false image of tear of the supra spinatus m. on its anterior edge. This was due to a bad knowledge of the anatomy of the muscle and tendon and to a poor orientation of the frontal cut plane. This study was complete with MRI and anatomic study of 12 non embalmed cadaveric shoulders. The results showed that MRI was very sensitive (0.93) and specific (0.94) for the diagnosis of rotator cuff tears. MRI allowed also to show partial tears of the tendons of the rotator cuff. The authors propose a MRI classification of cuff lesions which permits to establish a good surgical planning.

[Surgical treatment of metastases from thyroid cancer in the axial skeleton. A retrospective study of 18 cases]. / Traitement chirurgical des métastases des cancers thyroïdiens au niveau du squelette axial. Etude rétrospective d'une série de 18 cas.

Between 1990 and 1997, 18 patients with a mean age of 55.5 years (11 females, 7 males) underwent surgical treatment for a metastasis from thyroid cancer involving the axial skeleton. At the time of surgery all patients had a poor prognosis: 7 metastases revealed the thyroid cancer, all 18 patients had a neurological or mechanical complication, 9 had multiple metastases, all were over 40 years of age. After arteriography with embolization, the surgical procedure consisted of curettage of the tumor and reconstruction, followed by treatment with iodine 131. The survival rate 3 years after surgery was 50%. At the last review, the functional outcome was good and 17 patients had total neurological recovery. Four complications occurred: 1 operative hemorrhage, 3 postoperative infections. Four patients had local recurrence of the metastasis with a one-year survival rate of 20%. When the thyroid cancer was revealed by the axial metastasis, the 3-year-survival rate was 42%. In cases with huge metastases, the 3-year-survival rate was 71%. It appears from these data that surgical treatment of metastases from thyroid cancer in the axial skeleton still achieves a good functional outcome even in cases where neurological or mechanical complications had occurred before surgery.

[Revision arthroplasty of the shoulder for painful glenoid loosening: a series of 14 cases with acromial prostheses reviewed at four year follow up]. / Arthroplastie d'épaule itérative pour descellement glénoïdien douloureux: quatorze cas reprix par prothèse à appui acromial revus au recul moyen de 4 ans.

PURPOSE OF THE STUDY: We present the results of a continuous series of 14 patients who underwent revision arthroplasty of the shoulder for painful major loosening of the glenoid component. MATERIAL AND METHODS: Mean follow-up was four years after revision. Loosening was diagnosed seven and a half years after the primary arthroplasty. The diagnosis of loosening was based on the association of a painful impairment of the shoulder with increasing radiolucency or migration of the component. The degree of pain alone guided the surgical decision. The posterior approach provided wide exposure. A glenoid component with an acromial fixation was used in all cases. RESULTS: The loosening was confirmed in all cases at surgery. Two were early failures of the fixation. The glenoid required a bone graft in all cases. The acromion was a useful landmark for proper positioning of the prosthesis. Fixation with cement and screws provided a strong fixation allowing immediate rehabilitation exercises. Good fixation of the glenoid component was achieved in all cases. After seven years follow-up there has been evidence of iterative loosening in one patient. In another case, one screw broke, suggesting forthcoming loosening. Twelve cases had no or very little pain. Two painful cases were associated with anterior migration of the humeral head. DISCUSSION: Even when the local conditions are unfavorable, good implant fixation can be achieved by grafting the glenoid bone loss. Functional improvement is essentially due to pain relief. CONCLUSION: This series, the largest published to date on revision surgery of painful loosening of total shoulder arthroplasty, demonstrated that iterative fixation is technically possible and can provide highly significant pain relief.

[Recent fractures of the scapula. Apropos of 43 cases]. / Les fractures récentes de l'omoplate. A propos de 43 cas.

The authors have studied a series of 43 fractures of the scapula. They confirm the results are generally good. However, 12 displaced fractures of the neck of the scapula have been seen. All were treated conservatively with only one good result, the other results being fair or poor. These results are explained by the fact that displaced fractures of the neck disorganize the coraco-acromial arch. This type of fracture should be surgically treated as an articular fracture by open reduction and plate fixation. Fractures of the glenoid should also be treated surgically.

[Pelvic and spinal giant metastases from thyroid carcinomas: report of 8 cases]. / Localisations pelviennes et rachidiennes de métastases géantes des carcinomes thyroïdiens: à propos de 8 cas.

PURPOSE OF THE STUDY: We report 8 cases of giant metastases in 7 patients with a pelvis or spinal localization in patients with differentiated carcinoma of the thyroid gland. MATERIAL AND METHOD: Surgery was indicated for major functional disorders: pathological fracture, neurological complications. All patients were treated by embolization, tumor resection and reconstruction. All patients were given suppressive doses of thyroid hormones and 6 received complementary radiotherapy. Radioactive iodine, 100 mCu was also given in 5 cases. Outcome was analyzed retrospectively. RESULTS: Two postoperative infections were successfully treated by surgical cleaning in one operation. There were no surgery-related neurological complications. One patient died in the immediate postoperative period due to the cancer. Mean follow-up in the other patients was 4 years. Functional outcome was excellent without local recurrence or mechanical complications. DISCUSSION: These results suggest that surgical resection of giant bone metastases from thyroid carcinomas can provide favorable functional outcome similar to that achieved for small-sized metastases.