Tolerance and effect of sodium thiosulfate in calcific tendinitis of the rotator cuff.

BACKGROUND: Calcific tendinitis of the rotator cuff is one of the most common causes of shoulder pain. Ultrasound-guided percutaneous lavage of calcific tendinopathy is performed when conservative treatments have failed. Sodium thiosulfate (STS) has recently been used with success in the treatment of tumoral calcinosis. The goal of this phase II study was to assess the tolerance and the feasibility of STS lavage of calcific tendinopathy. METHODS: We included patient with type hard calcifications. Patients were treated with puncture and lavage followed by injection of STS in the calcification. VAS pain at rest and during activities, ultrasound, and X-ray were evaluated at 1 week and 1 and 3 months. RESULTS: Seventeen patients were included. Baseline VAS at rest and during daily activities was a mean 40.2 ± 25.9 and 65.5 ± 21.6 respectively. All patients underwent the entire procedure with no adverse event. Calcium backflow could be obtained in 15 patients (88.2%). Five patients (30%) had more than 50% decrease of their calcific deposit size at 1 month and 8 (47%) patients at 3 months. VAS pain during activities and at rest decreased significantly at 3 months (p = 0.0004; p = 0.001). Efficacy would be demonstrated if 60% of the patients had more than 50% decrease size of their calcification CONCLUSION: Overall, STS was well tolerated with no side effect occurring during the procedure and the follow-up. However, no significant effect on calcium disappearance could be demonstrated compared with what is expected without STS. New studies using larger volume and repeated injections of STS are now needed. CLINICAL TRIAL REGISTRATION NUMBER: NCT02538939Key Points• Lavage of calcific tendinopathy of the rotator cuff with sodium thiosulfate is feasible• No adverse events have been observed after or in the 3 months after the procedure• We could not demonstrate that sodium thiosulfate increases the chance of calcium disappearance• New studies using larger volume and repeated injections of STS are needed to further explore the interest of sodium thiosulfate in the treatment of calcific tendinopathy.

[Use of methoxyflurane on acute pain during burn dressing in adult consultation]. / Utilisation du méthoxyflurane sur la douleur aiguë lors du pansement en consultation des brûlés adultes.

INTRODUCTION: The objective was to compare the short-term efficacy of methoxyflurane vs. MEOPA on acute pain during burn dressing in consultation, the secondary outcome was to assess the patient's comfort and the quality of the dressing performed. MATERIALS AND METHODS: Monocentric, prospective study from April 2018 to January 2019. Men and women>18 years presenting acute burn on<10% SCT were included. A pain≥4 on the numerical scale (from 0 to 10) at the beginning of the treatment established the indication of methoxyflurane or MEOPA, with randomization done by a nurse. The following data were collected: burn description, performed debridement, pain assessment by numerical scale: on arrival, at the beginning of care, after 6 to 10 inhalations for methoxyflurane or 3 to 4minutes of inhalation for MEOPA and at the end of care. RESULTS: Sixty patients were included, 30 in each group. There was a decrease of -2.47 points of numerical scale when initiating methoxyflurane against -1.53 points for MEOPA (P=0.08). Patients were significantly less painful when stopping treatment in the methoxyflurane group -4 points vs -2 points (P=0.001). Methoxyflurane significantly improved the debridement of the burn (P=0.018). CONCLUSION: Methoxyflurane is more effective than MEOPA in acute pain in burn dressing, improved patient comfort, and improved dressing quality.

Utilisation précoce de l'irm pour l'évaluation du niveau d'amputation des membres dans la prise en charge des brûlures électriques à haute tension.

High-voltage electrical burns are rare, but the functional prognosis is often disastrous. Electrical currents are responsible for a wide range of injuries and their clinical assessment is difficult. For a case of severe electrical burn, and based on the literature, the authors performed an early MRI to elaborate their surgical strategy and avoid multiple surgeries by determining the level of amputation. Analysis of the different MRI signals and the per-operative study of the tissues led the team to take an early surgical approach and we were able to determine the level of limb amputation. Early analysis of lesions by MRI imaging allows us to consider a more aggressive surgical approach and thus reduce the number of interventions and the duration of stay in the intensive care unit.

Reliability of a new hip lateral view to quantify alpha angle in femoroacetabular impingement.

BACKGROUND: Radiographic measurement of the alpha angle (AA) in femoroacetabular impingement (FAI) is not well codified and invasive techniques such as MR- or CT-arthrography remain the gold standard. Excessive acetabular coverage described in pincer-type FAI can be seen on plain radiographs but has never been quantified and anterior center edge (ACE) angle, described on the false-profile view (FP) to measure anterior acetabular coverage has never been evaluated in FAI. HYPOTHESIS: In this study we wanted to determine if a plain radiograph could efficiently measure AA compared to CT-arthrography and if ACE could quantify the acetabular coverage in FAI. MATERIALS AND METHODS: We developed a hip view combining a lateral view and a FP, called profile view in impingement position (PIP). Twenty-six patients operated for FAI had CT-arthrography, PIP and FP. Nineteen control subjects had the PIP. AA were measured twice by three raters and ACE once. We compared AA measured on patients between CT and PIP, on PIP between patients and controls, ACE measured on patients between PIP and FP, and did a reproducibility analysis. Means were compared by paired or unpaired t-tests; reproducibility was measured by intraclass correlation coefficient (ICC). RESULTS: Mean AA was 65.8° (range, 48-85°) on CT-arthrography and 63.9° (range, 50-87°) on PIP (P>0.05). ICC for PIP measures were 0.8-0.9 for intra-rater and 0.6-0.9 for inter-rater reliability. Mean AA on PIP in patients was 63.3° (range, 52-87°) and 44.9° (range, 34-67°) in controls (P<0.001). Mean ACE was 26.8° (range, 14-41°) on PIP and 32.8° (range, 18-56°) on the FP (P=0.015). DISCUSSION: The PIP is a reliable view to measure the AA in FAI as measures on PIP and CT-arthrography were not significantly different with a good reproducibility. All of the painful hips and 2 controls had an AA>50°. PIP was not efficient to measure ACE. LEVEL OF EVIDENCE: Level III, case-control study.

Development of a per-operative procedure for concentrated bone marrow adjunction in postero-lateral lumbar fusion: radiological, biological and clinical assessment.

PURPOSE: Addition of bone marrow to the bone graft in the postero-lateral lumbar arthrodesis is a widely used technique. Bone marrow brings stem cells and growth factors contained in the platelets, favorable for bone growth. Adjunction of concentrated bone marrow should create better conditions and may increase bone growth. METHODS: Simple blind randomized clinical, prospective, monocentric trial was conducted. Fifteen patients underwent lumbar arthrodesis. During surgery, a fraction of the bone marrow harvested was centrifuged. One side received this concentrate with autologous bone and ceramics; the other side received the same graft with unconcentrated bone marrow. A quantitative study, realised with a volume calculating software on CT-scan images, determined the cortical bone volume in the graft post-operatively and at 3 months. The osteoprogenitor cells, nucleated cells and platelet concentrations were determined. RESULTS: The biological study found an average concentration of six times for the nucleated cells, 3.5 times for the platelets and 2.2 times for the osteoprogenitor cells. The comparison of the mean cortical bone volumes post-operatively and at 3 months was not significantly different. CONCLUSIONS: Despite the concentration obtained, there was no increase of bone growth by adding concentrated bone marrow. However, the number of stem cells in bone marrow was low and maybe a stronger concentration is needed to obtain a difference. The 3D reconstruction of the graft and the analysis of the graft's volume using a novel software was efficient according to the similarity of the graft's volume post-operatively in all patients.

[Rating of tumoral growth in non-operated primary or recurrent extra-abdominal aggressive fibromatosis]. / Etude de la croissance tumorale des tumeurs desmoïdes extra-abdominales (FDEA) primitives ou récidivées non opérées.

PURPOSE OF THE STUDY: Extra-abdominal aggressive fibromatosis (EAAF) is a benign desmoid tumor with a potentially aggressive behavior. Surgical treatment is compromised by a very high rate of recurrence, sometimes with significant morbidity. We conducted a prospective surveillance of our patients (clinical and MRI) with EAAF to search for prognostic factors. MATERIAL AND METHODS: This cohort included 17 patients with EAAF. For nine patients, biopsy alone was performed. For eight, the tumor was a recurrence after surgical removal. Patients were seen for a clinical assessment and MRI every six months. RESULTS: Median follow-up was 42 months (range 6-114). Three patients worsened clinically with pain or functional impairment. One patient required neurosurgery to control pain (good stable outcome). MRI showed progression for two tumors (12%) but with a short follow-up since diagnosis (9 and 14 months), in one case despite medical treatment. Three tumors regressed and twelve remained stable on successive MRI. On average the tumor growth lasted ten months. DISCUSSION: Tumor growth was never noted beyond 36 months. This notion of an interruption in tumor growth is mentioned sporadically in reports on EAAF, which have generally included recurrent tumors. To our knowledge this is the first series reporting tumors left in place a followed with modern imaging techniques. The high rate of spontaneous interruption of tumor growth must be counterbalanced with the difficult task of local treatment: the risk of recurrence is particularly high after surgery and functional sequelae can be significant when wide resection is proposed in an anatomically difficult localization. The precise role for surgery, and combined radiotherapy, remain to be determined. There are only scarce reports on general treatments. Considering these facts, we propose that surgical resection should not be considered the only solution for the treatment of EAAF. Further work is needed to define the useful contribution of simple surveillance of these benign tumors.

[Complications of fluoroscopy-, ultrasound-, and CT-guided percutaneous interventional procedures]. / Complications des gestes interventionnels percutanés sous contrôle radioscopique, echographique ou scanographique.

The purpose of this article is to describe potential complications following the most common image-guided (fluoroscopy, ultrasound or CT) percutaneous interventional procedures, both diagnostic and therapeutic, thoraco-abdominal and musculoskeletal, as well as to review risk factors and the best practice recommendations. Prior to any interventional procedure, it is necessary to ascertain the absence of any abnormality in coagulation, to secure enough time to explain the procedure to the patient, and to adhere to strict sterile technique. Indeed, infections and hemorrhagic complications are the principal causes of mortality and morbidity for all procedures. Following lung biopsy, CT scan detects an immediate pneumothorax in 30% of patients. Major complications following percutaneous liver biopsy occur within 3 to 6 hours. Following a percutaneous drainage, complications occur in less than 10% of cases. Following a radiofrequency thermal ablation of malignant tumors, the mortality rate is low (0,5 to 1,4%), infection and hemorrhage are the most frequent complications. While rare, septic arthritis is the main complication that can follow musculoskeletal procedures and is a cause of medical malpractice lawsuits brought by patients.

[Subfascial lipomatous tumors: management in a series of 37 consecutive cases]. / Tumeurs graisseuses sous-aponévrotiques: stratégie de prise en charge à propos d'une série continue de 37 cas.

PURPOSE OF THE STUDY: The prognosis of subfascial lipomatous soft tissue tumors depends greatly on their histological type ranging from benign lipomas that cause little local or general problems to the severe prognosis of liposarcomas that exhibit both local and distant extension. However, the clinical presentation of the two types of tumors may be similar and thus quite misleading, sometimes leading to inappropriate management and severe consequences. The main objective of this study was to determine whether the preoperative work-up in patients treated for musculoskeletal tumors within our recruitment zone is adequate, allowing appropriate therapeutic decisions. In addition, we wanted to know what explorations are most pertinent for the differential diagnosis between benign and malignant subfascial lipomatous soft tissue tumors. MATERIAL AND METHODS: Thirty-seven patients with subfascial tumors were included in this study. There were 16 with benign lipomas and 21 with liposarcomas. All the patients with benign lipomas but only 9 (43%) of those with liposarcoma had received initial care within our recruitment zone before final diagnosis. Two cases had been referred after biopsy and 1 after resection by morcellation; the 9 others were secondary referrals after tumor recurrence. Only 5 of these 12 referred patients had had an MRI exploration prior to surgery, 2 with an erroneous interpretation. An MRI series was obtained for all the patients with benign lipoma and for the 9 with liposarcomas who attended our units directly. A biopsy was also obtained in case of suspected liposarcoma. Two radiologists blinded to the final diagnosis reviewed the available MRI to assess their diagnostic value for subfascial lipomatous soft tissue tumors. RESULTS: No case of recurrence, after marginal resection (10 cases) was noted for lipomas. Six are under observation with regular MRI (with no change in size or signal). Four patients with liposarcoma died from their disease (19%) and 2 who had undergone "curative" resection had a recurrence (12%). Incorrect or imprecise (incomplete, incorrectly interpreted or no MRI) preoperative diagnosis led to additional morbidity with 3.4 surgical procedures (mean per patient) compared with 1 in patients who had had undergone a complete work-up and whose diagnosis was established after multidisciplinary discussions. Among the diagnostic elements available before pathology, only MRI findings had diagnostic value for subfascial lipomatous soft tissue tumors: for benign lipoma positive predictive value=92% and negative predictive value=93%. DISCUSSION: The clinical course of the benign lipomas and the sarcomas in this series confirm the radically different prognosis of these two tumors, both in terms of local extension and survival. Inadequate management in the initial diagnostic stages-i.e. lack of MRI with contrast injection, biopsy and multidisciplinary interpretation prior to treatment-raises the risk of higher morbidity, particularly a significantly greater number of reoperations, and progression to a higher grade of malignancy for two tumors. Our retrospective analysis enabled us to develop a decision making tree for patients with subfascial lipomatous tumors. Prospective validation will be necessary.

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.

Successful monitoring of neurogenic mixed evoked potentials elicited by anterior spinal cord stimulation through thoracoscopy during spine surgery.

STUDY DESIGN: Neurogenic mixed evoked potentials were recorded after thoracoscopic spinal cord stimulation in patients undergoing video-assisted spine surgery. OBJECTIVE: To demonstrate the feasibility and value of thoracoscopic spinal cord monitoring. SUMMARY OF BACKGROUND DATA: Video-assisted thoracic surgery recently has been proposed as a new technique for thoracic spine surgery. It can be used for anterior spinal release of patients with severe spinal deformities and for thoracic hernia removal. METHODS: Five patients undergoing video-assisted thoracic surgery for spinal fusion were studied. Neurogenic mixed evoked potentials were elicited by electrodes seated into intervertebral discs through thoracoscopy and recorded from peripheral nerves of the lower limbs. Moreover, the study included the case of a patient with a thoracic hernia who underwent video-assisted thoracic surgery with combined thoracoscopic neurogenic mixed evoked potential and standard somatosensory evoked potential monitoring. RESULTS: Neurogenic mixed evoked potentials were recorded consistently after spinal cord stimulation in all patients. For the patient with a thoracic hernia, neurogenic mixed evoked potentials suddenly disappeared, whereas somatosensory evoked potentials were not significantly modified, leading to surgery interruption. Neurogenic mixed evoked potentials progressively reappeared after a 30-minute delay. Postoperation examination revealed a Brown-Sequard's syndrome with incomplete right motor deficit. CONCLUSIONS: Neurogenic mixed evoked potentials evoked by anterior stimulation through thoracoscopy are of interest for spinal cord monitoring when posterior electrical stimulation is impossible, and they provide reliable information regarding spinal motor pathways.

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.

[Tomodensitometric image of the lumbar spine. Study of 150 patients hospitalized for discal sciatica]. / Perception de la tomodensitométrie lombaire. Etude chez 150 patients hospitalisés pour sciatique discale.

OBJECTIVES: There would be some discordance between patient expectations and expert recommendations concerning computed tomography (CT) of the spine for discal disorders. We analyzed patient opinion. PATIENTS AND METHODS: At admission, a 25-item questionnaire was given to 150 patients hospitalized in a rheumatology unit for discal sciatica. Patients were asked to express their expectations concerning the CT exploration. RESULTS: Seventy percent of the patients had already undergone CT explorations requested by a general practitioner (55%) or a specialist (45%), 20% had had two CT explorations and 20% magnetic resonance imaging. Seventy-five percent felt they should have had a CT scan earlier, 85% thought a CT should be performed for back pain of less than one month duration and 96% in case of sciatica for 2 months or more. Patients felt their exploration came "late" because the physician was under financial pressure (52%), had incorrectly appreciated the patient's need (28%) or was incompetent in the matter (22%). Nevertheless, 15% of the patients recognized that the CT scan could be useless and 89% knew that all cases of hernia are not operable. Thirty percent recognized that hernias can go undetected on the CT scan and 78% that they may remain asymptomatic. Finally, 56% of the patients thought that the CT scan would not change their treatment and only 23% expected to undergo surgery sooner because of the CT exploration. DISCUSSION: Several factors would explain what patients expect from CT exploration of the spine: patient understanding that causes other than discal hernia can cause back pain (98%) or sciatic (77%); their fear of having another disorder (56% wanted to be reassured, which would explain in part why 27% hoped the CT would improve pain, 50% wanted to "see" their discal hernia, and 30 wanted to eliminate another cause of their pain); patient distrust of clinical diagnosis which they felt was less pertinent than CT (80% of the patients for generalists and 70% for specialists). Patient expectations did not appear to be limited by fear of irradiation (unrecognized by 90% of the patients) nor the cost of the exploration which was overestimated by 70% of them.

Lumbar spinal stenosis: a review.

Neurologic compromise due to degenerative disorders of the lumbar spine are designated by the generic term "lumbar spinal stenosis". Differences in the interpretation of this term exist across the fields of pathology, radiology, and rheumatology, creating significant confusion. Rheumatologists view lumbar spinal stenosis as a functional rather than an anatomic entity and hold that its diagnosis should be based on clinical grounds. As in disk disease, imaging studies lack sensitivity and specificity, are poorly correlated with the level and severity of manifestations and are of no assistance for predicting the preoperative or postoperative outcome. A detailed history is the mainstay of the diagnosis and also carries great weight for estimating the level of impairment due to spinal stenosis. In contrast, "objective" physical findings have little predictive value and are poorly correlated with both quality of life indicators and postoperative outcomes. The effect of surgery remains unpredictable in the individual patient. Remarkable uniformity has occurred among published series regarding the rate of poor surgical outcomes (about one case in three), postsurgical worsening of symptoms (one case in six) and postsurgical complications (one case in ten). Accurate data are lacking on the short-term and long-term efficacy of conservative therapy (local corticosteroid injections and kinesiology). Randomized studies are needed to compare conservative therapy and surgery in terms of quality of life and other long-term outcomes in patients who fail initially to respond to conservative management. Improved knowledge of the natural history of this ill-defined syndrome is among the benefits expected from such studies.

Dorsal scalloping by calcified disc herniation.

SUMMARY OF BACKGROUND DATA: Disc herniation responsible for scalloping of vertebral body had been reported only at the lumbar level. RESULTS: The authors report on an unusual etiology of dorsal scalloping. A voluminous and calcified dorsal disc herniation was responsible for this, and within the center of the mass there was an unexpected hypersignal on nuclear magnetic resonance imaging. CONCLUSION: Scalloping does not preclude disc herniation, even at the dorsal level. Hyperintensity in T1-weighted images can reveal calcifications, as indicated in previous studies.