[Return to pivot-contact sports after anterior cruciate ligament reconstruction: patellar tendon or hamstring autografts]. / Reprise du sport pivot-contact après reconstruction du ligament croisé antérieur : technique au tendon patellaire ou aux ischiojambiers.

PURPOSE OF THE STUDY: The purpose of this study was to compare outcome at 12 months and return of pivot-contact sports in male subjects having undergone anterior cruciate ligament reconstruction using a patellar tendon or four-strand hamstring autografts. MATERIAL AND METHODS: Sixty male athletes underwent arthroscopic ligament reconstruction using either a patellar graft or a hamstring graft. The two groups were comparable for age (25+/-6 years), height (177+/-5cm), weight (74+/-8kg), pivot-contact sports, and level of sports activity. The two groups were reviewed at four, six and 12 months. The Lysholm and Tegner scores were noted and isokinetic tests were performed (60 and 180 degrees /s). The comparison was completed at twelve months with the single-legged hop test, instrumental laximetry (KT-1000) and the Arpege and IKDC 2000 scores. Return to pivot-contact sports at the same level was assessed at last follow-up after having been encouraged at the nine-month check-up. RESULTS: At twelve months, the function scores (IKDC 2000, Lysholm: 99.4+/-5 versus 98+/-5, Tegner: 6.8+/-1 versus 6.5+/-1) and single-legged hop test (94+/-5% versus 95+/-7%) were comparable. Instrumental laxity measurements however demonstrated greater laxity with the hamstring graft (2.7+/-0.4mm versus 1.8+/-0.3mm, p=0.02). A knee extension deficit was observed for the patellar technique (10+/-8%, p<0.01). A knee flexion deficit was observed for the hamstring technique (11+/-14%, p<0.01). Return to pivot-contact sports at the same level was comparable and concerned 53% [95%CI 41-66] of the knees after hamstring ligament reconstruction and 56.6% [44-68] of the knees after patellar ligamentoplasty. CONCLUSION: The two techniques of anterior cruciate ligament reconstruction were found to be equivalent in terms of return to pivot-contact sports at the same level. It was noted however that this resumed sports activity was possible for only one out of two subjects despite the systematic medical and surgical surveillance and selection of subjects free of any complication.

[Retraining between months 4 and 6 after anterior cruciate ligament reconstruction with hamstring graft: comparison between cycling and running with an untrained operated subject group]. / Réentraînement à l'effort entre le quatrième et le sixième mois après ligamentoplastie de genou au DIDT: comparaison de la pratique de la bicyclette et de la pratique du footing avec un groupe témoin non réentraîné.

OBJECTIVE: To study the effect of cycling or running retraining between 4 and 6 months after patients underwent anterior cruciate ligament reconstruction with hamstring grafting (Semitendinosus-Gracilis) compared with that in patients who had the same surgery but were untrained. METHOD: Patients who had undergone surgery for an anterior cruciate ligament reconstruction by the same surgeon who used hamstring grafting were included if they were free of knee pain 4 months after the surgery. After giving consent, patients were randomized to receive controlled retraining (cycling or running 3 times a week) or not. The effect of retraining was measured by the evolution of the knee isokinetic peak torque at 60 degrees/s and 180 degrees/s 6 months after surgery. RESULTS: Fifteen patients were retrained with cycling (GI), 17 with running (GII) and 15 patients did not retrain (GIII). Before retraining, the 3 groups had the same peak torque deficit, measured at an angular speed of 60 degrees/s and 180 degrees/s, for knee extensors (GI: 33+/-11% and 27+/-8%; GII: 30+/-13% and 24+/-10%; GIII: 31+/-15% and 24+/-13%, respectively) and knee flexors (GI: 26+/-11% and 20+/-13%; GII: 20+/-14% and 17+/-13%; GIII: 19+/-15% and 14+/-15%, respectively). After retraining, progress measured at 60 degrees /s of knee extensors and flexors on the operated knees was 18+/-9% and 16+/-10% for GI, 16+/-9% and 11+/-11% for GII and 12+/-15% and 8+/-12 for GIII, respectively. Progress measured at 180 degrees /s followed the same evolution. After comparison of the 3 groups, any significant difference was put in relief according to the type of retraining. CONCLUSION: Retraining after anterior cruciate ligament reconstruction is necessary for patients to practice their previous sport. In our study, aerobic cycling or running between 4 and 6 months after surgery did not improve peak torque in the operated knee extensors and flexors. However, these 2 types of retraining are well-tolerated.

[Consequences of pain on isokinetic performance after anterior cruciate ligament reconstruction using a semitendinosus and gracilis autograft]. / Conséquences des douleurs à l'effort sur les performances isocinétiques après ligamentoplastie du genou aux tendons ischio-jambiers: étude longitudinale.

PURPOSE OF THE STUDY: The purpose of this study was to investigate isokinetic performance of the knee twelve months after ligamentoplasty of the anterior cruciate ligament using four-strand hamstring autografts. We wanted to ascertain the effect of exercise-induced postoperative pain. MATERIAL AND METHODS: Between January 2001 and January 2003, at total of 75 patients underwent arthroscopic hamstring ligamentoplasty performed by the same surgeon. Isokinetic measurements were obtained at 4, 6, and 12 months postoperatively. At four months, four subpopulations were identified depending on the presence or not of exercise-induced pain. RESULTS: Fifty-two patients were pain free, seven presented exercise-induced posterior pain, nine exercise-induced anterior pain and seven diffuse pain with more than 5 degrees limitation of extension and 10 degrees for flexion. Isokinetic measurements at an angular speed of 60 degrees /s performed at the fourth postoperative month were compared with the pain-free population and demonstrated a significant flexion deficit in patients with exercise induced posterior pain (32% vs 18%, p = 0.04), significant extension deficit in patients with exercise-induced anterior pain (45% vs 30%, p = 0.02), and significant deficit in extension (58% vs 30%, p = 0.001) and flexion (39% vs 18%, p = 0.01) in patients with diffuse pain and limited joint motion. Certain deficits persisted one year after surgery. Patients did not achieve their prior level in contact pivot sports if they presented exercise-induced anterior pain. The population with diffuse pain and limited joint motion only resumed line sports. DISCUSSION: It is not easy to ascertain the origin of knee pain after ligamentoplasty. Posterior pain at the harvesting site occurs after hamstring reconstruction (defective regeneration or incomplete disinsertion with muscle retraction). The hamstring technique can also lead to anterior pain involving all the structures of the extension system. Diffuse pain with limited joint motion is related to "minor" reflex dystrophy. CONCLUSION: A mean 10% extensor and flexor isokinetic deficit can be expected one year after four-strand hamstring ligamentoplasty. Isokinetic tests performed four months postoperatively in patients with exercise-induced pain can provide objective evidence of difficult recovery. Posterior exercise-induced pain is associated with a flexion deficit of more than 30%. Anterior pain with exercise is associated with 45% deficit in extension. Diffuse pain with limited joint motion is associated with more than 40% in flexion and more than 55% in extension. These quantitative results enable the surgeon to inform the patient concerning potential sports level after repair since recovery will be longer with greater deficit.

Drug interactions between voriconazole, darunavir/ritonavir and tenofovir/emtricitabine in an HIV-infected patient treated for Aspergillus candidus lung abscess.

We report an unusual case of pulmonary aspergillosis in a patient with AIDS and we demonstrated the drug-drug interactions between voriconazole, darunavir/ritonavir and tenofovir/emtricitabine. The combination darunavir-ritonavir-voriconazole should be avoided.

Traditional uvulectomy in Niger: a public health problem?

Although traditional uvulectomy, a procedure which consists of cutting away a part of the uvula, has been reported in several sub-Saharan African countries, in Maghreb and in Israel, epidemiological and anthropological data on this practice are rare. Severe complications may require hospitalization. The goal of this study was to assess the prevalence of this traditional procedure in Niamey, capital of Niger, the incidence of its severe complications and the beliefs and practices related to it. By the age of 5, 19.6% of the children in our survey had undergone uvulectomy. Severe complications of uvulectomy represented 7.8/1000 cases of hospitalization for children under 15 years of age. Complications were infections (including tetanus), hemorrhage and passage of the cut piece of uvula further down the respiratory tract. The children who had undergone uvulectomy belonged significantly more often to the Hausa ethnic group (66.2%) than to the majority Zarma ethnic group (18.3%) or to the other ethnic groups (15.5%). This can be explained by the fact that, in some Hausa subgroups, uvulectomy is systematically performed on the 7th day after birth, during the naming ceremony, to prevent death due to a 'swelling of the uvula'. In the other Hausa sub-groups and in the other ethnic groups, uvulectomy is solely a curative practice, both for children and adults, for vomiting, diarrhea, anorexia, the child's rejection of the breast, growth retardation and fever. Uvulectomy is performed in Niger by the barbers, whose functions are also to perform specialized surgery. These traditional surgeons claim there is no risk to this practice.(ABSTRACT TRUNCATED AT 250 WORDS)

Chondritis dissecans of concave articular surfaces (acetabulum and glenoid fossa). Two case reports.

We report two patients who had chronic mechanical pain due to substantial cartilage defects documented by arthrography. One of these patients had pain in the hip and declined surgical treatment. The other had pain in the glenohumeral joint; surgery found a fissure in the glenoid fossa cartilage and provided prompt pain relief. These two cases serve as reminders that investigation of the cartilage and subchondral bone in young patients with mechanical pain should not be confined to the convex articular surfaces, although these are more likely to sustain trauma-related damage than concave surfaces. In both our patients, the diagnosis required thin-section computed arthrotomography.

Severe obstetric morbidity of the third trimester, delivery and early puerperium in Niamey (Niger).

Epidemiological data about maternal morbidity are rare. The present study, carried out in Niamey, capital of Niger, was designed to measure the incidence of maternal morbidity among women delivering in hospital. Severe complications occurred in 232 of the 4,081 deliveries during the study period (6,450/100,000 live births). Maternal morbidity ratio was 11 times higher than the maternal mortality ratio. Incidence rates of the major morbidities (per 100,000 live births) were: obstructed labour 3,614, hypertensive disorders of pregnancy 1,159, haemorrhage 855, and puerperal sepsis 220. The incidence and case fatality rates of severe complications were both high, suggesting a lack of efficiency of maternal health services in spite of a high concentration of health personnel and a large accessibility to services in Niamey.

[Rehabilitation after shoulder rotator cuff surgery: in-patient or day-hospitalization (about 76 cases)]. / Rééducation des ruptures de coiffe de l'épaule opérées: prise en charge en hospitalisation en internat ou en hospitalisation de jour (à propos de 76 observations).

OBJECTIVE: To define criteria of orientation in day-hospitalized or in-patient after shoulder rotator cuff surgery. METHOD: Population of 71 patients (53.2 years +/-7) (76 shoulders) operated for rotator cuff tear by the same surgeon, then treated by physical therapy either in day-hospitalization or in-patient. Weekly, evaluation until the second month after surgery by setting as criteria: pain, passive and active range of motion and complications. RESULTS: Fifty-three shoulders benefited from rehabilitation therapy in hospitalization and 23 in day-hospitalization. There is no significant difference for criteria studied between the 2 populations except for pains at the fifteenth day after surgery. Pain and articular steepness seem more frequent if the surgery is complex. DISCUSSION: Day-hospitalization and in-patient give equivalent results, which explain themselves by the possibility of identical physical medicine and rehabilitation performances. The knowledge of the social context is important to choose the most adapted rehabilitation type because patients can benefit from assistance for the acts of the daily life and the domestic tasks. In-patient allows more comfort but implies a familial break.

[Anterior instability of the shoulder in athletes: apropos of 51 cases of stabilization using the Latarjet-Patte intervention]. / Instabilité antérieure de l'épaule chez le sportif: à propos de 51 cas de stabilisation par intervention de Latarjet-Patte.

We report the 45-month results of the Bristow Latarjet procedure in 48 patients (51 shoulders), all sportsmen. At review, 87% were satisfied, 71% practiced the same sport at the same level, and 74% had good or excellent objective results. Five patients reported recurrence of dislocation, external rotation was restricted more than 10 degrees in 36%, and 31% of the shoulders had radiological evidence of degenerative arthropathy. We compare the results with the literature, particularly concerning recurrent dislocation and osteoarthritis.

[Severe anterior sprains of the knee. Ligamentoplasty using the patellar tendon and reinforcement]. / Entorses graves antérieures du genou. Ligamentoplastie au tendon rotulien avec renfort.

One hundred four severe knee sprains, treated by ligamentoplasty, according to Marshall-MacIntosh, with a Kennedy polypropylene ligament augmentation device, were reviewed with an average follow-up of 31 months. The functional result was evaluated as good or excellent in 3 out of the 4 cases; 87% of the sportsmen were satisfied. The result was unsatisfactory in 26% of the cases, with rupture or an elongation of the transplant in 9 cases (8.6%), due for some patients to premature resumption of sports; in 4 cases reoperation was necessary. A failure is always possible, even with an augmentation; however, with a ligament augmentation device, early rehabilitation and sports are possible (after an average of 6 months). There was no intolerance: 2 cases of synovitis, with a rupture, were observed. The authors underscore the ill effects of a delay between the accident and the stabilization, which causes numerous lesions of the menisci and the cartilage. This is generally admitted in the literature. The ligament augmentation device has been used for 3 years; the operation is performed after the acute phase of the first lesions and at the latest during the first year after the injury, before secondary lesions of the menisci occur.

[Dislocation of the tendon of the posterior tibial muscle and fracture of the lateral malleolus. An other equivalent of bimalleolar fracture?]. / Luxation du tendon du muscle tibialis posterior et fracture de la malléole fibulaire. Un autre équivalent de fracture bimalléolaire?

The authors report on a new case of dislocation of the tibialis posterior tendon which was associated with a fracture of the lateral malleolus. They postpone a mechanism of injury based on the fibular fracture and emphasize differential diagnosis with rupture of the deltoid ligament. A retinacular repair was performed.

[Tumoral calcinosis of the foot in patient on hemodialysis]. / Calcinose pseudo-tumorale des deux pieds chez un hémodialysé chronique.

We report a new case of tumoral calcinosis in a renal failure patient. In this patient the pseudotumoral formation was found in an unusual localization on the medial border of the foot. The condition progressed with successive development of bilateral tumors and septic contamination. Pathology confirmed the diagnosis. The patient was successfully treated with tumor resection and renal graft. The origin of these pseudotumors remains a question of debate. Several pathogenc mechanisms have been put forward. Pronosis is always favorable. Several authors have suggested a phosphorus calcium work-up can be useful for classifying these tumors, guiding surgical treatment if required and managing the underlying cause.

Massive rotator cuff tears in patients younger than 65 years. What treatment options are available?

Management of massive rotator cuff tears is a therapeutic challenge in patients younger than 65 years, particularly if still working. According to our hypothesis, choice of the most appropriate treatment option mainly depends on the patient's functional status and on two predictive factors: height of the subacromial space and fatty muscle infiltration. This is a retrospective, multicenter study of a series of 296 patients younger than 65 years, including 176 males and 120 females with extensive or massive cuff tear. Patients had loss of elevation or external rotation or both in 162 cases. Four types of management of massive rotator cuff tear were performed in this study: anatomical watertight repairs, palliative treatments and partial repairs, watertight repairs using flaps or cuff prostheses and reverse shoulder prostheses. At follow-up, the Constant score (65.6+/-3.4) and active elevation (147.7 degrees +/-32 degrees) had significantly improved. Active external rotation with elbow at the side, and acromiohumeral interval (AHI) were unchanged. Work-related injuries, previous surgeries and complications were correlated with a poorer Constant score. At follow-up, the anatomical repair sub-group had a significantly better Constant score than the three other treatment groups but involved patients with unchanged AHI and a low degree of fatty infiltration of the infraspinatus muscle. The reverse shoulder prostheses sub-group showed better outcomes in terms of function benefits. The presence of a long biceps was correlated with the use of a palliative treatment. In the light of the results and literature, an approach to treatment is suggested related to the functional capacity of patients, the AHI and the degree of fatty infiltration of the infraspinatus and subscapularis muscles.

Ovine anterior cruciate ligament reconstruction using a synthetic prosthesis and a collagen inductor.

The evaluation of composite anterior cruciate ligament prostheses, the union of an inductor of collagen and a synthetic fibre, are described. They were implanted in 10 sheep models for six months. None of the ligaments were broken, and the dynamic radiography was stable during this time. After harvesting them, a histologic study was performed on the intra-osseou and intra-articular portion, and on the synovial tissue. Biocompatibility was excellent. An osseous anchorage was found in 50% of cases and a fibrous ingrowth with well oriented fibres in each case. The results of this study show that the matrix has only partially played its role, because there was no improvement of fibrous ingrowth compared with other studies. However this fact corresponds to results at only 6 months and it is necessary to identify the type of collagen.

Are pediatric wards in developing countries only places to die? A study of prior to hospitalization risk factors of death among 0-2 year old hospitalized children in Niamey, capital of Niger.

The 461 0-2-year-old children admitted to the paediatric ward of the National Hospital in Niamey over a 2-month period were closely followed up from admission to discharge or death. The in-hospital mortality rate was 30 per cent, a great proportion of deaths occurring during the first 24 h of hospitalization. Malnutrition was highly prevalent (76 per cent). Children referred from other health facilities (72 per cent) did not experience a higher probability of survival. Using multivariate analysis, three variables remained significantly associated with death: nutritional status, consultation of a traditional practitioner, and a neonate disease. Neonate diseases are the third major cause of death because of a high case fatality rate. For the other causes, the main underlying factor is malnutrition. Most in-hospital deaths are due to events that occurred prior to hospitalization. The role of hospitals' pediatric wards of developing countries is discussed.

The quality of risk factor screening during antenatal consultations in Niger.

A decade after the first International Conference on Safe Motherhood, maternal mortality remains very high in most West African countries, even in capital cities. The detection of high risk pregnancies, known as the risk approach, during antenatal consultations has been the basis of most maternal and child health programmes over the last decade. The effectiveness of antenatal care as a tool to prevent or predict obstetric complications is being questioned more and more. In addition to the scarcity of reliable data about the predictivity of most risk factors, the quality of the screening must be questioned. The goal of this study was to assess the frequency of risk factors among a sample of pregnant women attending antenatal care in Niger and to assess the quality of the screening of those risk factors. Overall, 330 pregnant women were enrolled in the study. Each woman was examined twice: the first time by a midwife, the second time by one of the authors but without knowledge of the results of the first consultation. Fifty-five percent of pregnant women had at least one risk factor, 31% had more than one. Ninety-one percent of the risk factors were detected at interview. The following risk factors were not systematically searched for by midwives: height (48.5%), blood pressure (43.6%), glycosuria (40.6%), vaginal bleeding (38.2%), oedema (37.3%), parity (17%), age (16%), previous caesarean section (15.2%), previous stillbirth (15.2%) and previous miscarriages (14.8%). This study has shown that, in Niger, the quality of screening for risk factors during antenatal consultation is poor. In the urban settings where this study took place, lack of personnel, lack of equipment, lack of time and poor compliance by women cannot be made responsible for this situation. While screening of these risk factors continues as policy, the quality of screening must be dramatically improved.

[The sheep: an animal model for ligament prostheses?]. / Le mouton: modèle animal pour les prothèses ligamentaires?

Ruptures of the anterior cruciform ligament is difficult to repair. Ligament prostheses are sometimes useful. We tested a ligament prosthesis which had the original property of combining a polyester braid with a matrix favouring collagen ingrowth. We implanted this prosthesis in the knee joint of 10 sheep after sectioning the anterior cruciform ligament at it origin. The ligaments were recovered after 6 months. We studied the functional and radiographic results. Tolerance was studied in samples of the articular fluid and synovial tissue. We evaluated bone attachment and fibrous growth using micro-radiography and specific coloration techniques. Samples were examined under electron microscope. No rupture was encountered. We observed a satisfactory functional and radiographic result. No intolerance was observed. The neoligament had a bony or mixed attachment in 60% of the cases and was comprised of oriented tissue in 90% of the cases. Vascular invasion was important. These findings are promising and suggest that long-term studies should be undertaken.

Multiple rheumatoid bursitis with migrating chylous cysts. Report of a case in a European woman and review of the literature.

We report a case of recurrent multiple bursitis (19 episodes at nine sites) requiring seven surgical procedures in a European women with a 38-year history of severe, nodular, destructive seropositive rheumatoid arthritis unresponsive to second-line drugs. The episodes of bursitis were not correlated with activity of the joint disease. Some cysts migrated over a considerable distance. At least two cysts contained chylous fluid. The histologic study of one cyst demonstrated a cholesterol crystal granuloma. Potential relationships linking cholesterol crystals, chylous cysts, and migrating multiple bursitis are discussed. The relevant literature is reviewed.