[Early failure of anterior bone block in multidirectional shoulder instability: a case report]. / Echec précoce d'une butée antérieure d'épaule dans le traitement d'une instabilité multidirectionnelle.

We report the case of a 47-year-old female patient who developed predominantly anterior multidirectional glenohumeral instability. After rehabilitation, this patient was treated surgically with an anterior coracoid bone block using the Latarjet technique. The second postoperative day, the control scan revealed posterior glenohumeral dislocation. The patient underwent a second operation for a posterior iliac block. At last clinical follow-up (six years), the patient had normal shoulder motion; shoulder function was considered excellent using the clinical scores. We recall the pathogenic hypotheses explaining multidirectional shoulder instability and discuss the proposed treatments. This case illustrates the difficult diagnosis and therapeutic management of multidirectional instability. Under general anesthesia, examination showed that posterior laxity predominated while paradoxically, the patient presented predominantly anteromedial dislocations. This case is also exceptional by the development of posterior dislocation, an unusual postoperative complication after an anterior bone block; we describe the therapeutic options. In the event of multidirectional instability with bone injuries, we recommend a block in the direction of the instability. Preoperative examination under general anesthesia can be helpful in understanding the mechanism of residual postoperative instability, which would require complementary surgical stabilization.

Finite element model of the human neck during omni-directional impacts. Part II: relation between cervical curvature and risk of injury.

A detailed 3D FE model of the human neck was used to assess a possible relationship between risk of injury and cervical spine curvature for various impacts. A FE model was previously developed, representing the head and neck of a 50th percentile human with a normal lordotic curvature. The model behaviour was omni-directionally validated for various impacts using published results. For the present study, the model was deformed in order to obtain a straight and a kyphotic curvature, and for each geometry, rear-end, frontal, lateral and oblique impact were simulated. Although results showed similar kinematic patterns, significant differences were found in the distribution and peak values of ligament elongations, forces and moments along the cervical spine for the three configurations. It was concluded that the variability observed on the curvature of the human cervical spine may have a significant influence both on the behaviour and on the risk of injury of the neck during impact.

The mini-invasive anterior extra peritoneal approach to the pelvis.

Retroperitoneal pelvic tumours are rare and their surgical approach is challenging. Various surgical approaches have been proposed. We present here an original mini-invasive anterior retroperitoneal approach the pelvic retroperitoneum, which was successful in a 26-year-old woman who had a benign schwannoma of the left sacral plexus. This technique presents advantages over other techniques that were considered in this case, as the least invasive and safest procedure.

[Sequelae of intra-articular calcaneal fractures: patterns and management]. / Chirurgie des séquelles des fractures du calcanéum: à propos de 24 cas.

PURPOSE OF THE STUDY: We reviewed retrospectively 24 feet with sequelae of transtalar process fractures of the calcaneum in order to identify the lesion pattern and determine optimal management options, both for acute and sequelar lesions. MATERIAL AND METHODS: There were fourteen men and nine women, mean age 42 years (19-73). Twenty-three had subtalar osteoarthritis, eight had calcaneocuboid osteoarthritis, and fifteen had lateral submalleolar conflicts. There were twelve fibular tendon dislocations or fissurations, three tarsal tunnel syndromes, and two plantar splinters. Prior to treatment, all patients complained of pain. Preoperatively, walking distance was less than 500 m for thirteen patients, 2000-3000 m for four, and greater than 3000 m for five. Mean subtalar joint motion was 30% (0-100%) compared with the healthy side and mean frontal misalignment of the rear foot was 6 degrees valgus. Physical examination, podoscopy and x-rays were obtained in all patients. The Kitaoka score was noted. RESULT: Mean follow-up was 36 months (24-72). Sequelae were treated with a single procedure or with combinations: subtalar arthrodesis (n = 23) including one in association with calcaneocuboid arthrodesis, tension on fibular tendons (n = 7), neurolysis of the posterior tibial nerve (n = 3), resection of plantar splinters (n = 2), resection of the lateral shell (n = 14), and osteotomy (n = 2) to lower the greater tubercle of the calcaneum because of pain when wearing shoes. The mean Kitaoka function score was 31.7/100 (14-79) preoperatively. After treatment, the mean score was 81.7/100 (31-94), giving a 73.2% gain. The outcome was considered good in sixteen feet, fair in six, and poor in two. Mean walking distance was greater than 3000 m for 18 patients. Mean frontal misalignment of the rear foot under loading was 4.5 degrees valgus and the podoscopy demonstrated flat foot in thirteen patients. Three subtalar arthrodesis required revision for nonhealing. DISCUSSION: Initial treatment of a fracture, particularly an articular fracture, of the calcaneum must avoid disabling postoperative pain and shoe wearing problems. These sequelae basically concern: subtalar and calcaneocuboid arthritis, lateral submalleolar conflict, fibular tendon injury, plantar splinters, tarsal tunnel syndrome, loss of height, and misalignment of the rear foot. At the sequelar stage, the physical examination is primordial to confirm the lesion and search for any complication which could develop later postoperatively when walking distance becomes longer. For nine patients with residual pain, four resulted from lesions which were missed at the preoperative physical examination. Arthrodesis of the subtalar joint should be preferred over realignment of the rear foot and can be associated with the treatment of conflicts. This management scheme allows treating during a single operative time all sequelae, thus limiting recovery time. A scan of the ankle and foot with or without opacification of the fibular tendons is needed to confirm the physical examination which, for us, remains the key to successful surgery.

Survival and therapeutic modalities in patients with bone metastases of differentiated thyroid carcinomas.

Data for patients with bone metastases (BMs) of differentiated thyroid carcinoma (DTC) were retrospectively studied to identify factors associated with survival. We especially studied the impact of therapies. Among the 1977 patients followed for DTC in our department from 1958 to 1999, 109 (77 females and 32 males; age range, 20--87 yr) presented BMS: All patients except 1 underwent total thyroidectomy, followed by radioiodine therapy (> or =3.7 gigabecquerels) in 95 cases. Survival rates at 5 and 10 yr were 41% and 15%, respectively. Univariate analyses indicated that a young age at BM discovery (P < 0.005) and the discovery of BM as a revealing symptom of DTC (P < 0.05) were features significantly associated with improved survival as well as radioiodine therapy (P < 10(-4)) and BM complete surgery (P < 0.02). Using multivariate analysis, the detection of BMs as a revealing symptom of thyroid carcinoma (P < 0.0005), the absence of metastasis appearance in other organs than bones during the follow-up (P < 0.03), the cumulative dose of radioiodine therapy (P < 0.0001), and complete BM surgery in young patients (P < 0.04) appeared as independent prognostic features associated with an improved survival.

Skeletal muscle regeneration and the mitotic clock.

Regeneration of muscle fibers following damage requires activation of quiescent satellite cells, their proliferation and finally their differentiation and fusion into multinucleated myotubes, which after maturation will replace the damaged fiber. The regenerative potential of human skeletal muscle will be determined, at least partly, by the proliferative capacity of the satellite cells. In this study, we have measured the proliferative life span of human satellite cells until they reach senescence. These analyses were performed on cell populations isolated from old and young donors as well as from one child suffering from Duchenne muscular dystrophy, where extensive regeneration had occurred. In order to see if there are any age-related changes in the myogenic program we have also compared the program of myogenic differentiation expressed by satellite cells from these subjects at different stages of their proliferative lifespan.

Symptomatic spinal epidural lipomatosis induced by a long-term steroid treatment. Review of the literature and report of two additional cases.

Spinal epidural lipomatosis associated with Cushing's syndrome is an uncommon complication (11 reported cases). Two additional symptomatic cases with neurologic deficit are described. Steroid treatment was systemic in the first case and local with epidural injections in the second. The second case is unique because no similar observations have yet been reported. In most cases, a preoperative computed tomographic scan establishes the diagnosis by demonstrating dural compression by an adipose mass. Myelography is far less specific. In some cases, the exact diagnosis is made at the time of surgery. The treatment is primarily surgical, with laminectomy over the length of the compression and the removal of the compressing fat. Neurologic recovery is dependent on two factors: the level of the compression and the adequacy of decompression.

Treatment of lower cervical spinal injuries--C3 to C7.

Injuries of the lower cervical spine are categorized according to the morbid anatomy of the lesion. Most often, such injuries are successfully treated by surgery through a posterior approach. After anatomic restoration, internal fixation with plates and screws provides for stability and arthrodesis. Of 221 cases of lower cervical spine injuries, posterior stabilization was accomplished in 89%. There was no secondary displacement in 85% of cases.

Transverse fracture of the upper sacrum. Suicidal jumper's fracture.

Thirteen patients with transverse fractures of the upper sacrum were studied to determine fracture anatomy, clinical presentation, and therapeutic approaches. The injury results from falls from a height and is usually associated with suicidal attempts by jumping. The position of the lumbar spine in lordosis or kyphosis at the time of impact determines which of three types of morbid anatomy will result. Because of associated polytrauma, fracture of the upper sacrum is often not recognized in the acute stage, and awareness of the possibility of such injury, especially in the presence of perineal neurologic deficit should result in securing good quality radiographic study, including tomograms. Surgical treatment is often required.

Vertebral metastases: a critical appreciation of the preoperative prognostic tokuhashi score in a series of 71 cases.

STUDY DESIGN: The utility of the Tokuhashi score was assessed in a retrospective study in 71 patients with vertebral metastases. OBJECTIVES: To study the importance of the site of the primary tumor as a parameter in the preoperative prognostic Tokuhashi score. SUMMARY OF BACKGROUND DATA: A preoperative score composed of six parameters, each rated from zero to two, has been proposed by Tokuhashi for the prognostic assessment of patients with metastases to the spine. METHODS: Seventy-one patients with vertebral metastases were studied. There were 34 cases of thyroid cancer metastases, 28 cases of renal cancer metastases, and nine cases of metastases of unknown origin. In each patient, a local and a systemic tumor search were performed. Patients were divided into groups based on the primary site of the tumor, and each group was analyzed separately. RESULTS: In cases of vertebral metastases of thyroid cancers, surgery to excise single metastases was found to provide good results, as was palliative surgery of multiple metastases. Vertebral metastases of renal tumors were rarely single, and the results of palliative surgery were less satisfactory. Vertebral metastases of unknown primary tumors had a poor outcome, regardless of whether surgery was excisional or palliative. The median survival period in patients with metastases of unknown primary tumors was significantly shorter than that in patients with renal or thyroid cancer metastases. CONCLUSION: The Tokuhashi preoperative score is successful as a prognostic tool. However, it attributes the same one-point rating to metastases of renal cancer and to those of unknown primary tumors. In the case of metastases of unknown primary tumors, this rating is too high and should be reduced to 0.

Hangman's fracture: the relationship between asymmetry and instability.

There is ambiguity concerning the nomenclature and classification of fractures of the ring of the second cervical vertebra (C2). Disruption of the pars interarticularis which defines true traumatic spondylolisthesis of C2, is often wrongly called a pedicle fracture. Our aim in this study was to assess the influence of asymmetry on the anatomical and functional outcome and to evaluate the criteria of instability established by Roy-Camille et al. We studied the plain radiographs and CT scans of 24 patients: 13 were judged to be asymmetrical, ten were considered unstable and 14 stable. Treatment was with a Minerva jacket in 15 fractures and by operation in nine. Surgery was undertaken in patients with severe C2 to C3 sprains. One patient with an unstable lesion refused operation and was treated conservatively with a poor radiological result. Our study showed that asymmetry of the fracture did not affect the outcomes of treatment and should not therefore influence decisions in treatment. The criteria of Roy-Camille seem to be reliable and useful. We prefer the posterior approach to the cervical spine, which allows both stabilisation of the fracture and correction of a local kyphosis.

Plating of thoracic, thoracolumbar, and lumbar injuries with pedicle screw plates.

This article describes a technique of plating thoracic, thoracolumbar, and lumbar injuries with pedicle screw plates. The shape of the plates is premolded to the spine curvature. The strength of the pedicles where the screws are implanted explains the good results of reduction and stabilization. This technique allows the surgeon either to reduce and fix a spinal fracture or to perform large approaches and extensive procedures when necessary.

[Chronic active hepatitis and cirrhosis induced by wild germander. 3 cases]. / Hépatite chronique active et cirrhose induites par la germandrée petit-chêne. Trois cas.

We report 3 cases of chronic liver injury that were observed after prolonged treatment with wild germander, a herbal medicine recently prohibited by French Ministry of Health, following several reports suggesting its hepatotoxicity. Chronic active hepatitis was found in 2 cases, and active cirrhosis in 1 case. The onset of hepatitis occurred after 6 to 7 months of treatment. Serum anti-nuclear and anti-smooth muscle antibodies were present in 2 patients. In 2 cases, wild-germander involvement was recognized several months after appearance of liver injury. Following treatment discontinuation, outcome was favorable in the 3 patients. These observations suggest that diagnosis of acute or chronic liver injury of unknown origin should always include the search for herbal medicine treatment.

Intraoperative ultrasonography evaluation of posterior vertebral wall displacement in thoracolumbar fractures.

Intraoperative ultrasonography (IOUS) was used to evaluate the location and compressive effects of intraspinal fragments in thoracolumbar fractures and the efficacy of reduction maneuvers in patients operated on for isolated or attached intraspinal fragments or for global posterior wall disruption. Dynamic IOUS was used to evaluate the effects of traction and lordosis. Fifty-eight patients were evaluated using a 7.5 MHz ultrasound probe, including 27 treated by impaction, 19 by removal of apparently isolated fragments, and 12 by traction followed by lordosis for global posterior wall disruption. IOUS had limitations and problems caused by split fragments and residual pedicular attachments that can compromise intraoperative maneuvers. The risk of secondary displacement of isolated fragments treated by impaction was very high. In particular, the pinching effect produced by T-shaped fractures was commonly responsible for secondary displacement. IOUS evaluation of canal clearance after fragment removal was satisfactory, but did not provide quantitative data. IOUS was easier to perform and apparently more reliable than intraoperative myelography. The dynamic IOUS data suggest that, except for severely tilted fragments that are completely free or remain attached to a pedicle, residual discal attachments significantly influence the likelihood of successful reduction.

[Surgical treatment of refractory tennis elbow. Apropos of 126 cases]. / Traitement chirurgical des épicondylalgies rebelles. A propos de 126 cas.

The authors have performed surgical treatment in 126 cases of resistant lateral tennis elbow. It is an easy and quick surgical technique, consisting of a desinsertion of the epicondylar muscles, with or without arthrotomy depending on the clinical symptoms associated with an articular lesions. One hundred and twelve cases have been successful and only fourty cases have obtained bad results. Best results are obtained in young people and in sportsmen presenting with an early lesion.

[Magnetic resonance imaging in lesions of the plantar aponeurosis]. / Imagerie par résonance magnétique (IRM) des lésions de l'aponévrose plantaire.

Exploration of sporting injures to plantar aponeurosis (PA) has up to now been based mainly on clinical examination, from which the diagnosis was established. Imaging technics such as standard radiography and ultrasound scanning have limitations allowing diagnosis to be made usually only by elimination, the lesion being very rarely visualized directly. Ten patients with hyperalgic lesion of plantar arch and functional impotence were explored by MR imaging, and in all cases this examination provided superior data confirmed at operation. The examination is painless and little invasive and can be carried out during the acute phase. The plantar aponeurosis is visualized directly between the muscle mass of the plantar arch and the fatty cushion. All three spatial planes can be investigated, most interesting data being obtained from the sagittal (in the PA axis) and frontal (comparative) planes.

[Recent fractures of the odontoid. Prognostic factors]. / Fractures récentes de l'odontoïde. Facteurs de pronostic.

A review of 92 recent fractures of the odontoid process suggests that they can be divided into two groups: stable fractures requiring no more than orthopedic treatment, and unstable fractures requiring surgery. Basing themselves on four main prognostic factors (direction and level of the fracture, distance between the fragments and age of the patients), the authors propose three types of surgical treatment differing in complexity and functional results: posterior C1-C2 arthrodesis, simple lacing with nylon threads and, quite recently, direct screwing by the antero-lateral approach.

[Extra-coracoid axillary approach to the gleno-humeral joint]. / Abord axillaire extra-coracoïdien de l'articulation gléno-humérale.

The authors advocate an elective approach to the lower part of the humeral (shoulder) joint by an original axillary route. This route is external to the short head of the biceps brachii muscle which is retracted together with the neurovascular bundle. The articular capsule is opened through the space between the subscapular and latissimus dorsi muscles. The skin incision is cosmetic. No muscle is cut, and in surgery for anterior instability of the shoulder the crucial area is automatically exposed. This technique, however, requires two assistants and may be arduous in very muscular subjects. In addition, the visibility of the rest of the humeral joint is limited. With a few precautions, the neighbouring vessels and nerves are well protected.

[Combination of propofol-sufentanil on somatosensory evoked potentials in surgery of the spine]. / Effets de l'association propofol-sufentanil sur les potentiels évoqués somesthésiques au cours de la chirurgie du rachis.

OBJECTIVES: Most anaesthetics depress cortical somatosensory evoked potentials (CSEPs). However, the modification of CSEPs during total intravenous anaesthesia using propofol remaining still unknown, justified this trial. TYPE OF STUDY: Open, prospective, clinical study. METHODS: Nine consecutive patients requiring CSEPs monitoring for spine surgery, were studied. Anaesthesia was induced with propofol (2.5 mg.kg-1 then 10 mg.kg-1.h-1) and sufentanil (0.50 micrograms.kg-1 then 0.25 micrograms.kg-1.h-1). Maximum positive (P40) and negative (N50) waweform latencies, and the peak to peak amplitude of CSEPs (posterior tibial nerve stimulation, cortical recording), were recorded before induction, 30 min, 1 and 2 h after induction, and at the end of surgery. Data are means +/- SD. RESULTS: Duration of anaesthesia was 260 +/- 73 min. Propofol induced significant lengthening of CSEPS (P40: from 37 +/- 10 up to 41 +/- 11 ms; N50: from 45 +/- 11 up to 51 +/- 14 ms), and a significant decrease in amplitude (from 1.9 +/- 0.9 down to 0.8 +/- 0.4 microV), but these changes were stable from 30 min after the induction to the end of spine surgery. A motor response was obtained 29 +/- 14 min after the end of anaesthetic administration. CONCLUSIONS: Total intravenous anaesthesia with propofol and sufentanil induces a small but stable lengthening of CSEPs latency and a stable decrease of its amplitude, which enable an appropriate monitoring of CSEPs during spine surgery.

[The anterior interosseous nerve syndrome. A rare lesion of a median nerve branch in the forearm. A case]. / Le syndrome du nerf interosseux antérieur. Une atteinte rare d'une branche du nerf médian à l'avant-bras. Une observation.

Apparently spontaneous and isolated lesions of the anterior interosseous nerve--a purely motor branch of the median nerve in the forearm--are extremely rare. Their clinical manifestations are fairly stereotyped, consisting of paralysis restricted to the long flexor muscle of the thumb, the deep flexor muscle of the index finger and the quadrate pronator muscle, without sensory disorders. The diagnosis is confirmed by electromyography. The syndrome may caused by traumas of the forearm or may develop spontaneously, although underlying anatomical abnormalities which may act as predisposing factors are not infrequently found in this case. The natural outcome may be favourable, but surgery may be required to release the nerve.