Acetabular reconstruction using morselized allograft and a reinforcement ring for revision arthroplasty with Paprosky type II and III bone loss: survival analysis of 95 hips after 5 to 13 years.

INTRODUCTION: Treatment of acetabular loosening and accompanying bone defects requires that the bone stock be rebuilt, the primary stability ensured, and the hip center of rotation restored to its anatomical location. HYPOTHESIS: Acetabular reconstruction using morselized allograft and a reinforcement ring will meet these requirements and ensure medium-term survival. PATIENTS AND METHODS: A retrospective study was performed on 95 acetabular revision cases (95 patients) performed between 1987 and 1995. The average age at revision was 69.5 years (42 to 86 years). Among these acetabular loosening cases, 12 cases had a type II Paprosky acetabular bone defect and 83 cases had a type III defect. RESULTS: The average follow-up was 8 years (5 to 13 years). There were seven post-operative dislocations, three deep infections, and two cases of repeated acetabular loosening. The cumulative survival rate at 14 years was 77.9% (95% CI: 61.96% to 93.84%). The average Postel Merle d'Aubigné (PMA) score improved from 8 (range 6-11) preoperatively to 14.8 (range 8-18) at follow-up; the Harris score improved from 35.3 (range 11-52) to 71.1 (range 40-94) (P<0.001). Based on the parameters outlined by Ranawat, the optimal centre of rotation was restored in 45% of cases. Graft integration was found to be good in 60% of cases. The reinforcement ring had migrated in five cases, including two cases of acetabular loosening that required an additional revision. The functional result was better when the hip center of rotation was restored (P<0.05). Conversely, the position of the hip center of rotation had no effect on graft integration or acetabular fixation. DISCUSSION: This series confirmed that acetabular reconstruction using morselized allograft and a reinforcement ring is effective in the medium term as a treatment for acetabular loosening with severe bone deficiency. It also revealed that restoring the hip center of rotation can improve functional results. LEVEL OF EVIDENCE: Level IV, retrospective study.

Pain after shoulder arthroscopy: a prospective study on 231 cases.

INTRODUCTION: Shoulder arthroscopy is reputed to be painful, but progression of postoperative pain after this type of surgery has never been described and analyzed. This study had a triple objective: the description, search for risk factors, and analysis of the long-term impact of postoperative pain. PATIENTS AND METHODS: This continuous prospective series includes 231 patients who underwent arthroscopic shoulder surgery. Pain was evaluated from D-1 to D3, then at D7, D30, and 1 year. Three pain criteria were noted: visual analog scale (VAS), morphine intake, and satisfaction with pain management. Surgery was performed under general anesthesia and/or interscalene block. A local anesthetic complement was administered in one of four modes: single subacromial injection, subacromial catheter, intra-articular catheter, or no complement. RESULTS: The VAS values remained less than 4 out of 10 during the entire study. Immediate postoperative pain was less than preoperative pain. It was followed by a pain bounce on D1 and D2 and did not return to a level significantly lower than its preoperative value until D30. Rotator cuff repair is the most painful surgery in the first postoperative days. The main risk factor for pain is a work related accident or occupational disease, associated with higher VAS values from D1 to 1 year and greater morphine intake. There was no correlation between immediate postoperative and 1-year VAS values. DISCUSSION, CONCLUSION: Pain after shoulder arthroscopy is relatively low and the efficacy of the intervention is long-lasting in terms of pain symptom. A pain bounce appears on D1, which must be taken into account, notably in the context of outpatient surgery. The use of local anesthesia is therefore advantageous. Despite the efficacy of postoperative pain relief protocols, their effect on longer term perspective was not demonstrated.

[Arthroscopic treatment of capsular shoulder stiffness.] / Traitement arthroscopique des raideurs capsulaires de l'épaule.

The shoulder capsular sitffness must be managed first by a physiotherapist and the arthroscopic release is indicated after failure. The clinical assessment is essential and reveals the loss of passive motion in specified direction. The x-rays and imaging are necessary for excluding the other etiologies of shoulder stiffness. The arthroscopic treatment is part of he treatment strategy which has to be explained to the patient. The arthroscopic treatment starts by measuring under anesthesia the loss of passive motion. The next step consists of the release of the rotator interval followed by resection of the anterior capsule. Finally, the posterior capsule is cut according to the location of the capsular retraction. The interest of the subacromial debridement is still of debate. The postoperative pain control and the rehabilitation are part of the treatment. The literature analysis demonstrates the efficiency of the arthroscopic treatment, even if the post-op care are often long. A delay of 6 months is currently necessary to obtain the final results. The main advantages of the arthroscopic treatment is to address specifically the retracted capsule and to perform a selective release which allow to start rehabilitation program early.

[Arthroscopic treatment of capsular shoulder stiffness]. / Traitement arthroscopique des raideurs capsulaires de l'épaule.

The shoulder capsular sitffness must be managed first by a physiotherapist and the arthroscopic release is indicated after failure. The clinical assessment is essential and reveals the loss of passive motion in specified direction. The x-rays and imaging are necessary for excluding the other etiologies of shoulder stiffness. The arthroscopic treatment is part of he treatment strategy which has to be explained to the patient. The arthroscopic treatment starts by measuring under anesthesia the loss of passive motion. The next step consists of the release of the rotator interval followed by resection of the anterior capsule. Finally, the posterior capsule is cut according to the location of the capsular retraction. The interest of the subacromial debridement is still of debate. The postoperative pain control and the rehabilitation are part of the treatment. The literature analysis demonstrates the efficiency of the arthroscopic treatment, even if the post-op care are often long. A delay of 6 months is currently necessary to obtain the final results. The main advantages of the arthroscopic treatment is to address specifically the retracted capsule and to perform a selective release which allow to start rehabilitation program early.

[Postoperative results after arthroscopic treatment of rotator cuff calcifying tendonitis, with or without associated glenohumeral exploration]. / Influence de i'exploration gléno-humérale associée sur les suites du traitement endoscopique des calcifications de la coiffe des rotateurs.

PURPOSE OF THE STUDY: Arthroscopic treatment of calcifying tendonitis usually includes a glenohumeral exploration first, followed by deposit removal via a bursal approach. The aim of this study was to analyze the relevance of a systematic glenohumeral exploration during arthroscopic treatment of calcified tendonitis of the rotator cuff. MATERIAL AND METHODS: Sixty-four consecutive patients treated by arthroscopic removal of calcific deposits in the rotator cuff were studied retrospectively. All patients had had at least six months of medical treatment. The treatment involved a glenohumeral approach in 32 patients (group GH) and an isolated bursal approach in 32 (group B). Both groups were similar with regard to epidemiological data and deposit aspect. In all cases, the deposit was removed from the bursal side and the cuff was not sutured. Assessment included duration of pain after surgery, Constant score, and x-ray aspect at six months follow-up and the delay for return to work. RESULTS: In the GH group, degenerative changes were noted on the labrum in three cases and a partial tear of the supraspinatus in two. No lesions noted in the glenohumeral joint required specific treatment. Postoperatively, the average duration of pain was significantly higher in group GH than in group B (11 weeks versus 6 weeks, p < 0.05) with a significant latency in return-to-work (12 weeks versus 5 weeks, p < 0.05). At six months follow-up, there was no difference between the groups for Constant score and deposit disappearance. DISCUSSION: Systematic exploration of the glenohumeral joint is not relevant in the arthroscopic treatment of calcified tendonitis and has a negative effect. Considering these results and those previously published in the literature, we recommend using an isolated bursal approach for arthroscopic calcifying tendonitis removal.

[Adaptative femoroplasty in total hip arthroplasty for proximal femur deformity]. / Fémoroplastie adaptive pour prothèse totale de hanche dans les déviations proximales majeures du fémur.

Using a illustrative case, we describe a new surgical approach simplifying implantation of a total hip prosthesis for major proximal femur deformity. The technique uses femorotomy and osteotomy to short circuit the deformation with a non-cemented modular femoral stem with shaft anchorage allowing reconstruction of the proximal femur around the prosthesis, i.e. adaptative femoroplasty.

[Surgical treatment of posterior instability of the shoulder joint using an iliac bone block or an acromial pediculated bone block: outcome in eighteen patients]. / Traitement de l'instabilité postérieure de l'épaule par butée iliaque ou acromiale: à propos d'une série de 18 cas.

PURPOSE OF THE STUDY: The posterior bone block procedure is a popular option for the treatment of involuntary posterior instability of the shoulder. The purpose of this study was to analyze the long-term results of this procedure using an iliac bone graft and to point out the advantages of Kouvalchouk technique using an acromial pediculated block. MATERIAL AND METHODS: Eighteen patients, ten men and eight women, mean age 27 years, were reviewed: thirteen were active in sports activities including four at the competition level. The duration of symptoms before surgery was four years on the average. One patient experienced recurrent dislocation, twelve suffered regular involuntary subluxation, and five had painful shoulders possibly related to posterior instability considering the arthroscopic findings. For nine patients (group 1), an iliac block was combined with the soft-tissue procedure. In nine others (group 2), the procedure described by Kouvalchouk was used to create a posterolateral acromial bone block with pediculated deltoid fibers. Functional outcome was assessed with the 100-point Duplay score. The position of the bone block and osteoarthritis were assessed on plain x-rays. RESULTS: Mean follow-up was 13.5 years in group 1 and 3.5 years in group 2. Four patients needed a revision procedure to remove a screw. At last follow-up, the average Duplay score was 78 points. Nine patients returned to their former sports activities. Seven patients were pain free and ten had moderate discomfort at effort. We did not observe any recurrent dislocation no subluxation but did have six patients who described apprehension. The mean Duplay score was 70 points in group 1 and 86 points in group 2. In two patients in group 1, the x-rays showed signs of grade 3 or 4 osteoarthritis, which was related to an intra-articular screw in one; the other patient had had the same degenerative signs before surgery. Two patients developed grade 1 osteoarthritis. DISCUSSION AND CONCLUSION: The bone block procedure is effective for posterior instability of the shoulder. Occurrence of osteoarthritis, compared with the anterior bone block, is lower after long-term follow-up. The results of the Kouvalchouk procedure with an acromial pediculated bone block look promising. We recommend an additional capsuloplasty when inferior hyperlaxity is associated with posterior instability.

[Efficacy of clozapine in the course of Huntington chorea: apropos of a clinical case]. / Efficacité de la clozapine (Léponex) au cours de la chorée de Huntington: à propos d'un cas clinique.

Previous case reports suggest the potential benefits of use of clozapine on psychotic symptoms in Huntington's chorea. Clozapine was administered to a 70 years old female patient admitted in the inpatient unit of the Department of Psychiatry for paranoïd delusions, hallucinations, comorbid with Huntington's chorea. Clozapine was administered with increasing regimen ranging from 25 to 200 mg/day after all other medications were discontinued. No other drugs were associated. Clinical evaluation was carried out at days 0, 28, 56, 112, 280 using the PANSS and Psychotic Depression Rating Scale. The clinical improvement was associated with plasma levels of clozapine which have been recognized as in therapeutic ranges by previous studies. Clozapine proved efficient on both positive and negative symptoms as assessed by a decrease of the PANSS ratings (-44%) between day 0 and day 56, (-61%) between day 0 and day 280, and by a decrease of Psychotic Depression ratings (-43%) between day 0 and day 56, (-60%) between day 0 and day 280. It was also effective on choreiform movements. The clinical improvement was associated with plasma levels of clozapine which have been recognized as in therapeutic ranges by previous studies. A lower daily dose than those classically used in schizophrenia was sufficient to obtain efficient treatment.

Restoration of latent inhibition by olanzapine but not haloperidol in entorhinal cortex-lesioned rats.

RATIONALE: Latent inhibition (LI) refers to the decrease in conditioned response induced by the repeated non-reinforced pre-exposure to the conditioned stimulus before its pairing with the unconditioned stimulus during the conditioning stage. LI has been considered as a relevant animal model for the study of the biological bases of schizophrenia. LI has recently been demonstrated to depend on the integrity of the entorhinal cortex, as lesioning of this area disrupted LI. OBJECTIVES: The present study aimed to verify whether the classical neuroleptic haloperidol and/or the atypical antipsychotic olanzapine would prevent the effect of entorhinal cortex lesioning. METHODS: LI was studied in an off-baseline conditioned emotional response (CER) paradigm in which a tone is paired with a footshock. Entorhinal cortex lesions were produced by the electrolytic method. After a recovery period, both lesioned and control rats received either haloperidol (0.3 mg/kg), olanzapine (0.3 mg/kg) or vehicle before both the pre-exposure and conditioning stages of the experiment. RESULTS: In control rats, pre-exposure to the tone induced LI, which was affected by neither haloperidol nor olanzapine. Lesioning of the entorhinal cortex produced a deficit of LI, which was restored by olanzapine but not by haloperidol. CONCLUSIONS: This result suggests a dissociation of the anatomical and pharmacological targets of the two drugs. The possible involvement of dopamine D3 receptors in the effects of olanzapine is discussed.

Clozapine dose-concentration relationships in plasma, hair and sweat specimens of schizophrenic patients.

The aim of the present study was to establish an analytical method for the determination of clozapine in sweat and to determine whether the clozapine level in hair and sweat were correlated to the daily dose of clozapine delivered to patients. Twenty-six subjects treated with clozapine at 200-700 mg/day for refractory psychosis were included in the study. Clozapine was determined in plasma by liquid chromatography coupled to a diode array detection system, after extraction with an organic solvent at pH 9.5. Clozapine was extracted from hair and sweat patches specimens by incubation in methanol overnight at 40 degrees C. The residues were analyzed by gas chromatography coupled to mass spectrometry in the electronic impact mode of detection. It was possible to determine clozapine in concentrations ranging from 30 to 1016 ng/ml in plasma (n = 22), from 0.17 to 34.24 ng/mg in hair (n = 23) and from 49 to 5609 ng/patch in sweat (n = 20). Preliminary results suggest a lack of correlation between daily regimen of clozapine and plasma levels of the drug. Therefore, a better dose-concentration relationship was observed in our study between daily dose and hair concentration (r = 0.542, P < 7%) or between daily dose and sweat concentration (r = 0.589, P < 6%), but with wide variations for patients at the same posology. However, the idea of using quantitative drug measurements in hair or sweat to ascertain whether a patient has taken his treatment exactly as prescribed will remain inapplicable.

Entorhinal but not hippocampal or subicular lesions disrupt latent inhibition in rats.

Latent inhibition (LI) is the deficit of conditioning resulting from repeated nonreinforced preexposure to a conditioned stimulus before its pairing with an unconditioned stimulus. There are cumulative data showing that large lesions of the hippocampal formation disrupt LI. However, the effects of selective lesions of the different components of the hippocampal formation have never been directly addressed in the same study and conditioning paradigm. The first experiment of the present study aimed at investigating the effects of excitotoxic lesions of the hippocampus, subiculum, or entorhinal cortex on LI in an "off-baseline"-conditioned emotional response procedure. Hippocampus or subiculum lesions had no effect on either LI or conditioning. In contrast, entorhinal cortex lesions disrupted LI without modifying conditioning. In Experiment 2, locomotor activity in a novel environment was assessed in the same rats. Whereas lesions of hippocampus increased locomotor activity, lesions of the subiculum or the entorhinal cortex were devoid of effect. Although both LI and habituation to novel environmental cues are thought to involve interactions between the hippocampal formation and the mesolimbic pathway, these results indicate a functional dissociation between the hippocampus and the entorhinal cortex.

[Atypical pharmacologic characteristics of an antipsychotic drug: clozapine]. / Atypicité pharmacologique d'un antipsychotique: la clozapine.

The discovery of clozapine in the mid-sixties and the demonstration of its clinical efficacy vis-à-vis recalcitrant schizophrenia contributed to the development of specific psychopharmacological research addressing the concept of atypical antipsychotics. The research has a dual aim. First, identifying the action sites, in the brain, specific to clozapine and to conventional neuroleptics, in order to classify those drugs on the basis of the observed differences in pharmacoclinical profile (low incidence of neurological side effects, activity on schizophrenic deficiency symptoms, activity vis-à-vis certain forms of recalcitrant schizophrenia). Recent studies have used tools derived from molecular biology to determine the action sites. The results of those studies suggest that there are at least four classes of antipsychotics (reverse neuroleptics, conventional neuroleptics, atypical neuroleptics and atypical antipsychotics). The second aim of the research is to determine the behavioral effects of each of the recognized classes of medication in order to determine the neurobiological substrates specific to the elementary cognitive operations impaired in schizophrenia. There is preclinical evidence to suggest that, in each area investigated (low incidence of neurological side effects, negative symptoms, cognitive symptoms), clozapine, a "dirty" drug, acts on different neurotransmission systems. The research thus aims to determine the pharmacological profile of the drugs of the future, designed to treat the cognitive deficiencies specific to the various types of schizophrenia.

[New antipsychotic agents: new paths of research on the notion of atypical agents]. / Les nouveaux antipsychotiques: nouvelles voies de recherche sur la notion d'atypicité.

The synthesis of new compounds called atypical neuroleptics such as amisulpride, clozapine, risperidone and now olanzapine has roused interest in the psychopharmacology of atypical antipsychotics. Since the synthesis of chlorpromazine in the early 1950s, subsequent therapeutic research has had two main goals: to define the mechanism of action of atypical neuroleptics and to search new compounds with both clinical efficacy and fewer side effects. The first one has widely been achieved, as it is clear that classical neuroleptics exert their effects by blockade of dopamine D2 receptors located in the ventral striatum. As a matter of fact, non specific blockade of dopaminergic receptors in the dorsal striatum also predicts extrapyramidal side effects. Moreover, classical neuroleptics have poor effects on negative and cognitive symptoms. That is why the search for new compounds has focused on two main goals: first, understanding the interactions of the neurotransmitters involved by the new drugs, second, characterizing their brain site of action. Achieving these two goals might enable us to precise the notion of atypicity as well as the classification of these new drugs.

Latent inhibition in conditioned emotional response: c-fos immunolabelling evidence for brain areas involved in the rat.

Latent inhibition refers to the fact that the formation of a conditioned association between a conditioned and an unconditioned stimulus is delayed by prior exposure to the conditioned stimulus. Latent inhibition is often investigated in the context of the conditioned emotional response, in which a tone serves as the conditioned and a footshock as the unconditioned stimulus. Such a paradigm was used for the present experiments in which some rats had been pre-exposed to the tone. Two hours after a subsequent exposure to the tone, c-fos immunocytochemistry was used to map activated brain areas. The density of immunoreactive neurones was measured in brain areas involved in audition, fear, stress and memory. For the basic conditioning group, pre-exposure to the tone decreased the density of labelled cells in the auditory system, areas involved in fear and stress and a number of limbic areas, namely the amygdala, the Ammon's horn of the hippocampus and the entorhinal cortex. In contrast, the density increased in three limbic areas: the dentate gyrus, the subiculum and the nucleus accumbens. Taken together, these data suggest that latent inhibition corresponds to alterations of sensory processing which renders difficult to state about the alteration of the transfers of the sensory information to structures involved in the control of emotional responses. As some brain areas show a specific increase of activity in cases of latent inhibition, further studies will investigate how the latter brain areas contribute to the other cell density alterations reported in this study and to the latent inhibition phenomenon itself.