Posterior shoulder instability managed by arthroscopic acromial pediculated bone-block. Technique.

In posterior shoulder instability (recurrent dislocation, involuntary posterior subluxation or voluntary subluxation that has become involuntary), surgery may be considered in case of failure of functional treatment if there are no psychological contraindications. Acromial bone-block with pediculated deltoid flap, as described by Kouvalchouk, is an alternative to iliac bone-block, enabling triple shoulder locking by the blocking effect, the retention hammock provided by the deltoid flap and posterior capsule repair. Arthroscopy allows shoulder joint exploration and diagnosis of associated lesions, with opening and conservation of the posterior capsule; it greatly facilitates bone-block positioning and capsule reinsertion. The present report describes the procedure in detail. LEVEL OF EVIDENCE: Technical note.

Retroverted glenoid reconstruction using glenoid plate in reverse shoulder arthroplasty.

PURPOSE: The objective of this study is to evaluate the clinical and radiological results of reverse shoulder arthroplasty (RSA) with glenoid plating in a consecutive series of patients affected by cuff tear glenohumeral arthropathy with glenoid retroversion >15°. We hypothesized that autologous humeral head graft may be better stabilized between the baseplate and the native glenoid surface with the use of a glenoid plate. METHODS: Twenty consecutive patients affected by cuff tear arthropathy with glenoid retroversion >15° (B2 or C according to Walch classification) were enrolled in this study. To reconstruct the glenoid, a dedicated plate was used in addition to the standard reverse shoulder baseplate and the glenosphere. Clinical and radiological assessment was performed using constant score (CS), subjective shoulder value (SSV), X-rays and CT scan at 6, 12 and 24 months of follow-up. Healing and resorption of the graft and detection of the glenoid version were assessed. RESULTS: Sixteen patients were available for final follow-up. The mean preoperative retroversion of the glenoid was 24°, while the post-op was 2° (p = 0.002). At 24 months of follow-up, mean CS and SSV were 61 and 70. Respect to preoperative scores, the results were statistically significant (p < 0.001). The last CT scan revealed: a complete healing of the graft in 100% of cases; graft resorption less than 25% in two patients (12.5%); glenoid retroversion of 4°. A negative statistically significant correlation was found between final CS and preoperative glenoid retroversion (0.039). CONCLUSIONS: The present study reports the favorable outcomes of retroverted glenoid reconstruction with glenoid plates in RSA, an alternative method to address severe glenoid deficiency. LEVEL OF EVIDENCE: Level IV, case series with no comparison group.

Preliminary clinical outcomes of Latarjet-Patte coracoid transfer by arthroscopy vs. open surgery: Prospective multicentre study of 390 cases.

BACKGROUND: The Latarjet-Patte procedure consisting in transfer and screw fixation of the coracoid process to the anterior glenoid is a treatment of reference for anterior shoulder instability. Over time, surgical innovations translated into a number of improvements and, in late 2003, an arthroscopically assisted variant of the procedure was described. OBJECTIVE: To evaluate and compare clinical outcomes of the modified Latarjet-Patte procedure performed by open surgery, arthroscopy with screw fixation, or arthroscopy with endobutton fixation. MATERIAL AND METHOD: A total of 390 patients who underwent surgery to treat anterior shoulder instability between March 2013 and June 2014 were included and divided into three groups depending on whether they were managed using open surgery with screw fixation, arthroscopy with screw fixation, or arthroscopy with endobutton fixation. Clinical findings were recorded pre-operatively then 6 months post-operatively and at last follow-up (mean, 27.7 months). Range of motion and apprehension test (arm in external rotation at 0°, 90°, and 140° of abduction) were assessed and the Walch-Duplay and modified Rowe scores were determined. RESULTS: Motion range restriction was minimal with all three techniques, and motion range continued to improve throughout follow-up. Apprehension in external rotation was noted at 90° of abduction in 11% of cases and at 140° of abduction in 4% of cases. The mean total Walch-Duplay score improved from 46 pre-operatively to 90.6 and the mean total modified Rowe score from 46 pre-operatively to 91.1. By statistical analysis, external rotation at 90° of abduction and internal rotation at 0° of abduction were better after open surgery, but the differences were of limited clinical significance. Recurrence was noted in 3.3% of cases, nerve injury in 0.8%, and infection in 1.5%. CONCLUSION: In this study, the three techniques produced similar clinical outcomes, with a stable shoulder and no joint stiffness.

Is anterior glenoid bone block position reliably assessed by standard radiography? A cadaver study.

BACKGROUND: Standard radiography with an antero-posterior view and Bernageau's glenoid profile view is the method most widely reported in the literature to assess coracoid bone block position and fusion. OBJECTIVE: The aim of this cadaver study was to determine whether the antero-posterior and Bernageau's radiographs provide a reliable and reproducible evaluation of the position of a coracoid bone block and its fixation screws. METHOD: An isolated scapula showing no evidence of osteoarthritis or other abnormalities was used. The coracoid process was transferred to the anterior glenoid rim. Fixation was with two slightly diverging malleolar screws, chosen of different sizes for ease of identification. Computed tomography (CT) was performed as the reference imaging technique. The standard radiographs were then obtained, using fluoroscopy to accurately position the scapula for the antero-posterior and Bernageau's views. This position was defined as 0°, and radiographs were taken at angles of 5°, 10°, and 15° in all three planes. All radiographs were taken during a single session to ensure that the distance separating the tube from the scapula remained unchanged. The images were exported to OsiriX for analysis. We measured the angles formed by the screws and the glenoid surface, as well as bone block position and overhang. Finally, we used 1-mm thick disks to evaluate bone-to-bone contact. RESULTS: No correlations were found between values by CT and by standard radiography (both views) for the screw angles or overhang. A space≤1mm between the neck of the scapula and the bone block was not visible on the standard radiographs in any of the positions. CONCLUSION: Standard radiography does not provide an accurate analysis of bone block position or bone-to-bone contact. CT is needed to assess bone block and screw position and bone-to-bone contact. LEVEL OF EVIDENCE: Level III.

Functional outcomes after open versus arthroscopic Latarjet procedure: A prospective comparative study.

INTRODUCTION: The Latarjet procedure provides effective stabilization of chronically unstable shoulders. Since this procedure is mainly performed in a young athletic population, the functional impact is significant. Published data does not shed light on the time needed to recover work-related or sports-related function. Performing this procedure arthroscopically may improve functional recovery. This led us to carry out a prospective, multicenter study to compare the functional recovery after arthroscopic versus open Latarjet procedure. MATERIAL AND METHODS: Between June and November 2014, 184 patients were included in a prospective multicenter study: 85 in the open group and 99 in the arthroscopy group. The patients were evaluated preoperatively with the WOSI score. The early postoperative pain was evaluated on D3, D7 and D30. The WOSI score was determined postoperatively at 1, 3, 6 and 12 months of follow-up. RESULTS: The functional scores of the shoulder in both cohorts were identical overall preoperatively. In the immediate postoperative period, the arthroscopy group had statistically lower pain levels on D3 and D7. The postoperative WOSI was improved in both groups at 3 months, then continued to improve until it reached a plateau at 1 year. The WOSI score was better in the arthroscopy group at 3 months, but better in the open group at 6 months. CONCLUSION: This study found that a Latarjet procedure performed arthroscopically generates less immediately postoperative pain than when it is performed as an open procedure. The Latarjet procedure (whether open or arthroscopic) improves shoulder function, with normal function returning after 1 year.

[Risk of deep venous thrombosis during an air flight: prevention and counselling at the counter]. / Le risque de thrombose veineuse profonde lors d'un voyage en avion : prévention et conseil à l'officine.

Worldwide air traffic reaches about 2.3 billion passengers per year. The increasing number of persons at thrombo-embolic risk, together with potentially severe or fatal complications of deep venous thrombosis, suggests community pharmacists can give basic preventive advice to persons identified as at risk.

[Reconstruction of the trapeziometacarpal joint and the first metacarpal bone by reversed free osteocutaneous dorsalis pedis flap]. / Reconstruction de l'articulation trapézométacarpienne et du premier métacarpe par un lambeau ostéocutané retourné de deuxième métatarsien.

A case of reconstruction after first metacarpal resection by reversed free vascularized osteocutaneous pedis flap is presented. This procedure avoids bone resorption and preserves the trapezio metacarpal joint contrary to conventional bone graft. A double rotation is applied to the flap: the head of the metatarsal becomes proximal and the palmar side becomes dorsal. The metacarpo-phalangeal joint undergo arthrodesis. With a follow up of three years, there is no pain, the Kapandji score is 8/10 (very good range of motion), there is no osteoarthritis.

[Treatment of the psychological and behavioural disorders of Alzheimer's disease]. / Maladie d'Alzheimer, traitement des troubles psychologiques et comportementaux.

When psychological and behavioral disorders of Alzheimer's disease appear suddenly, somatic, iatrogenic and reactive or relational psychological causes must be ruled out or treated before concluding that the cause is lesional. Non-pharmacological interventions should be privileged for the prevention and management of behavioral manifestations of mild to moderate intensity: psychological support of the patient (short therapies), training the caregiver, work on daily habits, reorganization of the home, behavioral measures against apathy and especially agitation, rehabilitation strategies, and therapy involving music, light, aromas, etc. Pharmacological therapies are only moderately effective in these disorders. They must be targeted and follow a sequence of prescription that maximizes tolerance and distinguishes treatment of acute and chronic states. Anticholinesterase agents may be useful in this domain to prevent or ease some symptoms (especially apathy). The efficacy of memantine must be confirmed by additional data. Some selective serotonin reuptake inhibitors agents may be useful not only in depression but also anxiety, emotional disturbances, irritability and compulsiveness. Atypical neuroleptics are better tolerated than the classic ones. They are most effective in this context but must be reserved for specific indications and limited in time because of the increased risk of stroke. Other psychotropics (benzodiazepines, carbamates, antiepileptics) should be used cautiously in this context.

[Diagnosis of psychological and behavioural disorders in Alzheimer's disease]. / Maladie d'Alzheimer, diagnostic des troubles psychologiques et comportementaux.

Although Alzheimer's disease has long been considered mainly a cognitive disorder, behavioral and psychological symptoms are present from its onset and at all the stages of the disease in most patients. They must be identified from the beginning because they orient the diagnosis. They include affective and emotional disorders, delusions and hallucinations, disorders of instinctual behavior and behavioral problems. The best tool for assessing them is the Neuropsychiatric Inventory (NPI). They are generally related to neurobiological aspects of the disease but may, especially when acute, have multiple etiologies: somatic, iatrogenic, psychological and environmental. They condition the course of the disease. As a source of suffering and reduced quality of the life and as the primary cause of distress for the caregivers and hence of hospitalization and institutionalization, they increase the costs of care. The challenge today is to learn more about them and thus improve their treatment and especially their prevention.

[Delirious states in elderly persons. Clinical characteristics]. / Les états délirants du sujet âgé. Caractéristiques cliniques.

EXTENSIVE HETEROGENEITY: The nosology of delusional disorders in the elderly is still debatable. The nosology varies greatly from that of the younger adults. It is heterogeneous because of the age at onset of the symptomatology, etiology and behavioural consequences (agitation, aggressiveness) of the delusion. TWO DISTINCT CONTEXTS: We can distinguish between the long term, old, psychoses and the delusions having occurred later in life (after the age of 60). The outcome of the former is still unknown; but often progresses towards the reduction in symptomatology. In the latter, various etiologies are observed with, primarily, delusions associated with dementia, followed by thymus delusions, schizophrenic or non-schizophrenic psychoses, delusions related to cerebral-vascular disorders or sensorial dysafferentation. It is important to underline the fact that any de novo delusion occurring after the age of 65 must evoke an underlying deterioration. ENHANCING FACTORS: In addition to a genetic predisposition suspected in certain cases, vulnerability factors are usually found in the context of age: somatic comorbidity, loneliness, sensory deficiencies, cognitive impairment, polymedication, and addict attitude. FROM A DIAGNOSTIC POINT OF VIEW: The differential diagnosis is essentially made with mental confusion. The evaluation calls upon scales, either specific to the psychosis and similar to those used in adults (SANSS, PANSS, PDI), or global and intended for psychological dementia and behavioural disorders (NPI).

[Delirious states in elderly persons. Therapeutic modalities]. / Les états délirants du sujet âgé. Modalités thérapeutiques.

THE MAJOR THERAPEUTIC TRENDS: The treatment of psychosis in late life depends on the etiology of the delusion but also on its behavioral consequences (agitation, aggressiveness). We distinguish between the treatment of long term old psychosis and delusions occurring late in life (after the age of 60). FOR THE OLD PSYCHOSES: The reduction in the symptomatology often permits a reduction in the doses and the relay to atypical neuroleptics with improved tolerance. FOR DELUSIONS OCCURRING LATE IN LIFE: The treatment will be adjusted to the etiology of the delusion: delirious states associated with dementia, thymus delusion, schizophrenic or non-schizophrenic psychosis, delusion related to cerebral-vascular disorders or to sensorial dysafferentation. One should note that emotional and delusional disorders are often concomitant in the elderly. THE TWO TREATMENT AXES: The first therapeutic element is non-pharmacological: reassurance or even brief psychotherapy, family counseling and prevention of enhancing, notably environmental, factors. The pharmacological element preferably includes atypical anti-psychotics, antidepressants in some cases together with anti-epileptics in cases of concomitant rebellious aggressiveness. In cases of dementia with cholinergic deficiency (Alzheimer, Lewy body dementia, mixed dementia) cholinesterase inhibitors have demonstrated their efficacy on the hallucinations. Advice for a pertinent strategy of action should be provided.

[A new locking nail for proximal humerus fractures: the Telegraph nail, technique and preliminary results]. / Un nouveau clou verrouillé pour les fractures proximales de l'humérus.

We present a new nail, the telegraph nail, designed for the treatment of proximal fractures of the humerus. This nail has a new locking system providing a self-stabilization of the cancelous screws inserted in small fragments. We discuss the surgical technique and present preliminary results. The anterolateral approach and nail insertion through the medial and well vascularized part of the cuff is described for simple fractures. With the cup and ball technique, this nail can also be used for complex fractures of the proximal humerus with three or four fragments and major displacement. With this method, the nail is inserted before reduction and locked in the distal humerus before fixation of the head and tuberosities around the head once the targeting device removed. We report results for the first 64 nails inserted in our unit during the first year (1998-1999). Outcome was assessed at 11 months mean follow-up using the Constant score. Outcome was favorable, including in patients with complex fractures involving 3 or 4 separate displaced fragments. Besides providing an anatomically stable reconstruction, the telegraph nail has the advantage of allowing early mobilization of the shoulder joint. This method is a useful alternative to prosthetic reconstruction for traumatic fractures of the proximal humerus.

HIV-1-resistance phenotype conferred by combination of two separate inherited mutations of CCR5 gene.

BACKGROUND: Despite multiple exposures to HIV-1, some individuals remain uninfected, and their peripheral-blood mononuclear cells (PBMC) are resistant to in-vitro infection by primary HIV-1 isolates. Such resistance has been associated with a homozygous 32-base-pair deletion (delta 32) in the C-C chemokine receptor gene CCR5. We examined other mutations of the CCR5 gene that could be associated with resistance to HIV-1 infection. METHODS: We assessed the susceptibility of PBMC to in-vitro infection by HIV-1 isolates that use the CCR5 as the major coreceptor for viral entry in 18 men who had frequent unprotected sexual intercourse with a seropositive partner. We also did genotypic analysis of CCR5 alleles. One of the 18 exposed but uninfected men (who we refer to as ExU2) showed total resistance to in-vitro infection by CCR5-dependent viruses, and was found to carry a CCR5 delta 32 allele and a single point mutation (T-->A) at position 303 on the other allele. To find out whether the CCR5 mutation was restricted to ExU2's family or existed in the general population, we did genetic analyses of the CCR5 genotype in ExU2's father and sister and also in 209 healthy blood donors who were not exposed to HIV-1. FINDINGS: The m303 mutation found in ExU2 introduced a premature stop codon and prevented the expression of a functional coreceptor. The family studies revealed that the m303 mutant allele was inherited as a single mendelian trait. Genotype analysis showed that three of the 209 healthy blood donors were heterozygous for the mutant allele. INTERPRETATION: We characterise a new CCR5 gene mutation, present in the general population, that prevents expression of functional coreceptors from the abnormal allele and confers resistance to HIV-1 infection when associated to the delta 32 CCR5 mutant gene.

Dilution assessment of cervicovaginal secretions collected by vaginal washing to evaluate mucosal shedding of free human immunodeficiency virus.

A 10 mM concentration of lithium does not interfere with reverse transcription (RT) or PCR. Sampling of cervicovaginal fluid by vaginal washing, with lithium (10 mM) in the washing buffer as a marker of dilution, may be utilized to accurately determine in HIV-infected women, by quantitative RT-PCR, the genital shedding of acellular HIV RNA at the level of the mucosa itself.

[Memory clinics: role of day hospital]. / Consultations de la mémoire: la place de l'hôpital de jour.

The day hospital appears to be highly suitable for a memory clinic, not only as a complementary service, but also for teaching and clinical or epidemiologic research purposes. As regards diagnostic procedures, the possibility of doing tests and assessments in the same place and in a short time is a clear advantage for these often fragile patients. In the day hospital, clinical assessments can be coupled with the paraclinical tests required to make a diagnosis, with efficient technical resources on hand. Multidisciplinarity and close collaboration between the different specialists are the key elements in the diagnosis and long-term management of these patients, who also find the premises less worrisome than the hospital environment. The day hospital appears to be the ideal setting for monitoring and therapeutic management, being situated at the interface between hospital and community physicians.

[Dietetic prevention in elderly in France]. / Prévention diététique en gériatrie en France.

Beside effects of dietetic recommendations on cellular or tissular ageing, dietetic prevention in elderly aims, at avoiding nutritional deficiencies in healthy old individuals and thus, the occurrence of induced diseases. Requirements of healthy housebound elderly are not different from those of adults but, more than in adults, diet's quality and palatability are important to insure maintenance of intakes. Beyond these advises, dietetic prevention in geriatrics requires screening of physical, psychical and social handicaps frequently observed in very old persons. Their additional effects could deeply modify dietary balance, especially during an acute intercurrent disease or following modifications of the environment. The practitioner's part is essential in preventing malnutrition in an old person impaired by chronic diseases: preventing the outcome of a denutrition to an irreversible state may avoid a medical and social decompensation leading to institutionalisation.