Are patients with hypermobile Ehlers-Danlos syndrome or hypermobility spectrum disorder so different?

Diagnosing hypermobile Ehlers-Danlos syndrome (hEDS) remains challenging, despite new 2017 criteria. Patients not fulfilling these criteria are considered to have hypermobile spectrum disorder (HSD). Our first aim was to evaluate whether patients hEDS were more severely affected and had higher prevalence of extra-articular manifestations than HSD. Second aim was to compare their outcome after coordinated physical therapy. Patients fulfilling hEDS/HSD criteria were included in this real-life prospective cohort (November 2017/April 2019). They completed a 16-item Clinical Severity Score (CSS-16). We recorded bone involvement, neuropathic pain (DN4) and symptoms of mast cell disorders (MCAS) as extra-articular manifestations. After a standardized initial evaluation (T0), all patients were offered the same coordinated physical therapy, were followed-up at 6 months (T1) and at least 1 year later (T2), and were asked whether or not their condition had subjectively improved at T2. We included 97 patients (61 hEDS, 36 HSD). Median age was 40 (range 18-73); 92.7% were females. Three items from CSS-16 (pain, motricity problems, and bleeding) were significantly more severe with hEDS than HSD. Bone fragility, neuropathic pain and MCAS were equally prevalent. At T2 (20 months [range 18-26]) 54% of patients reported improvement (no difference between groups). On multivariable analysis, only family history of hypermobility predicted (favorable) outcome (p = 0.01). hEDS and HDS patients showed similar disease severity score except for pain, motricity problems and bleeding, and similar spectrum of extra-articular manifestations. Long-term improvement was observed in > 50% of patients in both groups. These results add weight to a clinical pragmatic proposition to consider hEDS/HSD as a single entity that requires the same treatments.

[The acute management of muscle injuries in 2018]. / Prise en charge des lésions musculaires aiguës en 2018.

Acute muscle lesions are frequent conditions in sports traumato-logy. Intrinsic traumatic mechanism (excessive stretch) is more prevalent that extrinsic mechanism (direct shock or lacerations). The diagnosis is generally based on the injury mechanism description together with the clinical examination. The ultrasonography is helpful in order to evaluate the severity of the lesion and the time to sports resumption. The initial management is based on the POLICE acronym: Protection, Optimal loading, Ice, Compression, and Elevation. For high grade muscle lesions, patients might benefit from either ultrasound-guided hematoma evacuation or surgical repair. Non-steroid anti-inflammatory drugs should be avoided within the first days. The rehabilitation should begin 48h after the trauma, whatever the severity of the lesion.

Les lésions musculaires sont fréquentes en traumatologie sportive. Le mécanisme traumatique est plus fréquemment intrinsèque (par élongation) qu'extrinsèque (par choc direct ou lacération). Le diagnostic se fait sur la base de la description du mécanisme lésionnel et de l'examen clinique. L'estimation de la gravité et des délais de reprise est aidée par les examens d'imagerie, comme l'échographie. La prise en charge immédiate se base sur le protocole POLICE (Protection, Optimal loading, Ice, Compression, Elevation). Les anti-inflammatoires non stéroïdiens sont à proscrire. Les lésions de haut grade peuvent bénéficier d'une ponction-évacuation d'hématome, voire d'une réparation chirurgicale. Il est recommandé de débuter une rééducation adaptée dès 48 heures après le traumatisme, quelle que soit la sévérité de la lésion initiale.

Achilles tendon allograft for an irreparable massive rotator cuff tear with bony deficiency of the greater tuberosity.

Management of combined bony and tendinous deficiency of the posterosuperior rotator cuff represents a challenge in young patients. In this case report, a 44-year-old woman that presented an osteonecrosis of the greater tuberosity had a pseudoparalytic shoulder. She beneficiated from a fresh-frozen Achilles tendon allograft with calcaneal bone, which was used to reconstruct the rotator cuff and the concomitant bony defect. At 12-month follow-up, the patient was pain free and had complete range of motion, normal strength, a SANE score of 95 and radiographically the allograft was healed. An Achilles tendon allograft may therefore be a viable surgical option to reconstruct a combine posterosuperior rotator cuff tear and greater tuberosity bone defect. Level of evidence IV.

Immunoglobulin deficiency in patients with chronic rhinosinusitis: Systematic review of the literature and meta-analysis.

BACKGROUND: Several studies have shown a high prevalence of immunoglobulin deficiencies in patients with chronic rhinosinusitis (CRS). OBJECTIVE: We sought to perform a systematic review and meta-analysis to estimate this prevalence more precisely and to identify patients who need substitution treatment. METHODS: All case series published after 1990 describing patients with CRS, which was defined as symptomatic rhinosinusitis for more than 12 weeks and documented immunoglobulin deficiencies (including deficiencies of IgG with subclasses, IgA, and IgM; specific antibody deficiencies; and potential common variable immunodeficiency), were retrieved. A meta-analysis of the proportion of any combination of common variable immunodeficiency, IgG deficiency, IgA deficiency, and IgM deficiency in patients with CRS was performed by using logit transformation of the prevalence. Recurrent CRS was defined as rhinosinusitis not controlled by appropriate conservative management for 4 months, and difficult-to-treat CRS was defined as noncontrollable rhinosinusitis despite successful sinus surgery and appropriate conservative management for at least 1 year. RESULTS: The meta-analysis revealed a prevalence of pooled IgG, IgA, and IgM deficiencies in 13% of patients with recurrent CRS and 23% of patients with difficult-to-treat CRS. The prevalence of IgG subclass deficiency (5% to 50%) and specific antibody deficiency (8% to 34%) was increased in patients with CRS, as was the prevalence of respiratory allergies in patients with recurrent CRS (31% to 72%). CONCLUSION: Immunoglobulin deficiency is a frequent condition in patients with CRS. An even higher prevalence of atopy was observed in patients with recurrent CRS. Therefore immunoglobulin titers and accurate allergy diagnostic workups are strongly recommended in these patients to provide specific treatments for symptom alleviation. However, there is a need for larger prospective studies addressing the effect of specific therapeutic interventions for CRS.

[Reverse shoulder arthroplasty]. / La prothèse totale d'èpaule inverse.

Shoulder pain is a common problem for general practitioners. The objectives of a shoulder arthroplasty are to improve the articular function and to provide pain relief. Anatomic shoulder arthroplasty is not the treatment of choice if a rotator cuff deficiency is associated with arthritis. In some circumstances (muscle or tendon deficiency) rotator cuff repair is technically impossible. Reverse shoulder arthroplasty (RSA) has opened new opportunities for patients suffering with shoulder conditions such as shoulder pseudoparalysis and revision surgery. RSA is rarely proposed to patients below the age of 60 but thereafter there is no age limit. With this procedure, the functional improvement can be achieved after days or weeks. A new surgical approach allows for early active mobilization without a specific rehabilitation period.

An atypical case of calf pain: Plantaris tendon axial instability.

Plantaris tendon (PT) might induce calf or Achilles pain. In this case report, a 59-year-old woman presented with axial instability of plantaris tendon; post Achilles tendon lengthening. She beneficiated from a needle tenotomy of the PT and had a prompt symptom alleviation. The patient was fully satisfied and had a SANE score of 95% at 12 months follow up and was able to return to moderate sports activities without limitations (hiking, Nordic walking). The instability of the PT might be considered for the differential diagnosis of medial calf pain for which needle tenotomy may be considered a valuable option.

Aquatic Therapy versus Standard Rehabilitation after Surgical Rotator Cuff Repair: A Randomized Prospective Study.

Introduction: Post-operative rehabilitation following rotator cuff tear repair (RCR) is important to promote tendon healing, restore strength, and recover normal function. Aquatic therapy in hot water allows body relaxation, which promotes patient conditioning for efficient rehabilitation. The aim of this study was to assess whether aquatic therapy is more efficient than standard (land-based) rehabilitation in terms of range of motion (ROM), function, and pain after arthroscopic RCR. Methods: We prospectively randomized 86 patients scheduled for arthroscopic RCR to either aquatic therapy (n = 44) or standard rehabilitation (n = 42) using block sizes of four or six. Patients were evaluated clinically at 1.5, 3, 6, and 24 months and using ultrasound (US) at 6 months. Two-way mixed ANOVA tests were performed to evaluate the effects of rehabilitation type (between-subjects factor) on ROM and patient reported outcome measures (PROMs) over time (within-subjects factor). Post-hoc inter-group comparisons at each time point were also conducted using Wilcoxon rank sum tests or unpaired Student t-tests and adjusted for multiple comparisons using the Bonferroni correction. Results: The two groups did not differ significantly in terms of demographic data or pre-operative characteristics, except for the Single Assessment Numeric Evaluation (SANE) score, which was lower in the aquatic therapy group (37.9 ± 23.6 vs. 55.6 ± 24.9, p = 0.019). The mixed model revealed the absence of interaction effect between the type of rehabilitation and time on PROMs and ROM except on the SANE score (p < 0.001), which was biased by the existing pre-operative difference mentioned above. Furthermore, none of the post-operative outcomes were statistically different between the two groups at 1.5, 3, 6, and 24 months. In addition, no significant difference could be noted regarding tendon healing rate (p = 0.443), complication (p = 0.349), workstop duration (0.585), or patient satisfaction (p = 0.663). Conclusion: Compared to the standard rehabilitation, the aquatic therapy did not yield superior clinical and functional outcomes after arthroscopic RCR when started immediately after the surgery.

Postoperative Mobilization After Superior Rotator Cuff Repair: Sling Versus No Sling: A Randomized Prospective Study.

BACKGROUND: Patients are commonly advised to wear a sling for 4 to 6 weeks after rotator cuff repair despite negative effects of early immobilization and benefits of motion rehabilitation. The aim of this study was to compare clinical and radiographic outcomes up to 6 months following rotator cuff repair with and without postoperative sling immobilization. METHODS: We randomized 80 patients scheduled for arthroscopic repair of a small or medium superior rotator cuff tear into sling and no-sling groups (40 patients each). Passive mobilization was performed in both groups during the first 4 postoperative weeks, and this was followed by progressive active mobilization. Patients were evaluated clinically at 10 days and 1.5, 3, and 6 months and using ultrasound at 6 months. Univariable and multivariable analyses were performed to determine if postoperative scores were associated with sex, age at surgery, immobilization, arm dominance, a biceps procedure, resection of the distal part of the clavicle, or preoperative scores. RESULTS: The sling and no-sling groups had similar preoperative patient characteristics, function, and adjuvant procedures. At 10 days, there was no difference in pain between the 2 groups (mean pain score [and standard deviation], 5.2 ± 2.3 versus 5.2 ± 1.9, p = 0.996). In comparison with the sling group, the no-sling group showed greater mean external rotation (23.5° ± 15.6° versus 15.3° ± 14.6°, p = 0.017) and active elevation (110.9° ± 31.9° versus 97.0° ± 25.0°, p = 0.038) at 1.5 months as well as better mean active elevation (139.0° ± 24.7° versus 125.8° ± 24.4°, p = 0.015) and internal rotation (T12 or above in 50% versus 28%, p = 0.011) at 3 months. Ultrasound evaluation revealed no significant differences at 6 months in tendon thickness anteriorly (p = 0.472) or posteriorly (p = 0.639), bursitis (p = 1.000), echogenicity (p = 0.422), or repair integrity (p = 0.902). Multivariable analyses confirmed that the mean American Shoulder and Elbow Surgeons (ASES) score increased with patient age (beta, 0.60; p = 0.009), the Single Assessment Numeric Evaluation (SANE) decreased with sling immobilization (beta, -6.33; p = 0.014), and pain increased with sling immobilization (beta, 0.77; p = 0.022). CONCLUSIONS: No immobilization after rotator cuff repair is associated with better early mobility and functional scores in comparison with sling immobilization. Postoperative immobilization with a sling may therefore not be required for patients treated for a small or medium tendon tear. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Differential Diagnosis Assessment in Ambulatory Care With an Automated Medical History-Taking Device: Pilot Randomized Controlled Trial.

BACKGROUND: Automated medical history-taking devices (AMHTDs) are emerging tools with the potential to increase the quality of medical consultations by providing physicians with an exhaustive, high-quality, standardized anamnesis and differential diagnosis. OBJECTIVE: This study aimed to assess the effectiveness of an AMHTD to obtain an accurate differential diagnosis in an outpatient service. METHODS: We conducted a pilot randomized controlled trial involving 59 patients presenting to an emergency outpatient unit and suffering from various conditions affecting the limbs, the back, and the chest wall. Resident physicians were randomized into 2 groups, one assisted by the AMHTD and one without access to the device. For each patient, physicians were asked to establish an exhaustive differential diagnosis based on the anamnesis and clinical examination. In the intervention group, residents read the AMHTD report before performing the anamnesis. In both the groups, a senior physician had to establish a differential diagnosis, considered as the gold standard, independent of the resident's opinion and AMHTD report. RESULTS: A total of 29 patients were included in the intervention group and 30 in the control group. Differential diagnosis accuracy was higher in the intervention group (mean 75%, SD 26%) than in the control group (mean 59%, SD 31%; P=.01). Subgroup analysis showed a between-group difference of 3% (83% [17/21]-80% [14/17]) for low complexity cases (1-2 differential diagnoses possible) in favor of the AMHTD (P=.76), 31% (87% [13/15]-56% [18/33]) for intermediate complexity (3 differential diagnoses; P=.02), and 24% (63% [34/54]-39% [14/35]) for high complexity (4-5 differential diagnoses; P=.08). Physicians in the intervention group (mean 4.3, SD 2) had more years of clinical practice compared with the control group (mean 5.5, SD 2; P=.03). Differential diagnosis accuracy was negatively correlated to case complexity (r=0.41; P=.001) and the residents' years of practice (r=0.04; P=.72). The AMHTD was able to determine 73% (SD 30%) of correct differential diagnoses. Patient satisfaction was good (4.3/5), and 26 of 29 patients (90%) considered that they were able to accurately describe their symptomatology. In 8 of 29 cases (28%), residents considered that the AMHTD helped to establish the differential diagnosis. CONCLUSIONS: The AMHTD allowed physicians to make more accurate differential diagnoses, particularly in complex cases. This could be explained not only by the ability of the AMHTD to make the right diagnoses, but also by the exhaustive anamnesis provided.

Efficacy of Platelet-Rich Plasma for the Treatment of Interstitial Supraspinatus Tears: A Double-Blinded, Randomized Controlled Trial.

BACKGROUND: The benefits of platelet-rich plasma (PRP) for the treatment of rotator cuff tears remain inconclusive, as it is administered either as an adjuvant to surgical repair or as a primary infiltration without targeting the index lesion, which could dilute its effect. PURPOSE: To determine whether PRP infiltrations are superior to saline solution infiltrations (placebo) at improving healing, pain, and function when injected under ultrasound guidance within isolated interstitial supraspinatus tears. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: In this single-center, double-blinded, randomized controlled trial, 80 adults with symptomatic isolated interstitial tears of the supraspinatus, confirmed by magnetic resonance arthrography, were randomized to PRP or saline injections. Each patient received 2 injections with a 1-month interval. The primary outcome was the change in lesion volume, calculated on magnetic resonance arthrography, at 7 months. The secondary outcomes were improvements in shoulder pain and the Single Assessment Numerical Evaluation (SANE) score at >12 months. RESULTS: Preoperative patient characteristics did not differ between the 2 groups. At 7 months, there were no significant differences between the PRP and control groups in terms of a decrease in lesion size (-0.3 ± 23.6 mm3 vs -8.1 ± 84.7 mm3, respectively; P = .175); reduction of pain on a visual analog scale (VAS) (-2.3 ± 3.0 vs -2.0 ± 3.0, respectively; P = .586); and improvement in SANE (16.7 ± 20.0 vs 14.9 ± 29.0, respectively; P = .650), Constant (8.6 ± 13.0 vs 10.7 ± 19.0, respectively; P = .596), and American Shoulder and Elbow Surgeons (19.5 ± 20.0 vs 21.9 ± 28.0, respectively; P = .665) scores. At >12 months, there were no significant differences between the PRP and control groups in terms of a reduction of pain on a VAS (-3.3 ± 2.6 vs -2.3 ± 3.2, respectively; P = .087) or improvement in the SANE score (24.4 ± 27.5 vs 23.4 ± 24.9, respectively; P = .846). At 19.5 ± 5.3 months, the incidence of adverse effects (pain >48 hours, frozen shoulder, extension of lesion) was significantly higher in the PRP group than the control group (54% vs 26%, respectively; P = .020). CONCLUSION: PRP injections within interstitial supraspinatus tears did not improve tendon healing or clinical scores compared with saline injections and were associated with more adverse events. REGISTRATION: NCT02672085 (ClinicalTrials.gov identifier).

Spirometry and provocation tests for vocal fold dysfunction diagnosis: a retrospective case series.

AIMS: Vocal cord dysfunction (VCD) is characterised by paradoxical inspiratory laryngeal motion and is often misdiagnosed as asthma. Definitive diagnosis of VCD is difficult, because laryngoscopy is positive only during symptomatic episodes or upon provocation with exercise or inhaled irritants. The aims of the study were to better characterise the symptomatology of patients with VCD and to evaluate the potential usefulness of less-invasive diagnostic tools, namely provocation tests and spirometry. METHODS: Retrospective case series of 84 patients with a typical clinical history of VCD, in whom at least one of the three following diagnostic tests were performed: laryngoscopy, provocation testing, or spirometry. RESULTS: The mean age of the patients was 51 years and 74% were women. The principal comorbidities were rhinosinusitis (60%), gastro-oesophageal reflux disease (56%) and atopy (54%). Diagnosis of VCD was confirmed in 73/84 cases (87%), by laryngoscopy (8%), spirometry (84%) and/or provocation tests (68%). CONCLUSIONS: VCD remains an underdiagnosed condition. A negative finding on laryngoscopy can lead to false negative diagnosis if it is done when the patient is asymptomatic. Here we show that a clinical suspicion of VCD, evoked by medical history, can be confirmed in many cases by less invasive diagnostic tools such as spirometry and provocation tests. Future well-conducted prospective case-control studies are needed to draw firmer conclusions and to improve the diagnostic accuracy of this condition.  .

Fosbury flop tear of the rotator cuff: diagnostic assessment with magnetic resonance arthrography.

OBJECTIVES: The aim was to assess the diagnostic performance of magnetic resonance arthrography (MRA) of the shoulder for the detection of "Fosbury flop" tears. METHODS: All patients undergoing arthroscopic rotator cuff repair were considered as potentially eligible for inclusion in this prospective case series. Preoperative MRAs were consecutively performed and compared with intraoperative findings being the gold standard control. Two experienced musculoskeletal radiologists, blinded to the arthroscopic findings, independently analysed all MRAs for the presence of typical signs of Fosbury flop tears. RESULTS: 423 patients were included. Among this group, 11 presented a Fosbury flop tear with a prevalence of 2.6%. Interobserver agreement was considered as excellent for thickened tendon, tendon stump, fluid accumulation, abnormal fibres orientationand adherences between tendon and bursa. The most sensitive and specific criterion was the tendon thickness[90.9% CI(62.3-98.4) and97.1% CI(95.0-98.3), respectively].  Conclusions: Fosbury flop tear is an uncommon condition that should be recognized to allow optimal anatomic repair. MRA is a valuable tool in making the diagnosing of this lesser recognized type of rotator cuff tear. An abnormally thickened supraspinatus tendon tear should especially raise suspicion for a Fosbury flop tear of the posterosuperior rotator cuff. Advances in knowledge: MRA is a valuable tool in making the diagnosing of Fosbury flop tears. An abnormally thickened supraspinatus tendon tear should especially raise suspicion for such lesion.

Subscapularis- and deltoid-sparing vs traditional deltopectoral approach in reverse shoulder arthroplasty: a prospective case-control study.

BACKGROUND: With the growth of reverse shoulder arthroplasty (RSA), it is becoming increasingly necessary to establish the most cost-effective methods for the procedure. The surgical approach is one factor that may influence the cost and outcome of RSA. The purpose of this study was to compare the clinical results of a subscapularis- and deltoid-sparing (SSCS) approach to a traditional deltopectoral (TDP) approach for RSA. The hypothesis was that the SSCS approach would be associated with decreased length of stay (LOS), equal complication rate, and better short-term outcomes compared to the TDP approach. METHODS: A prospective evaluation was performed on patients undergoing RSA over a 2-year period. A deltopectoral incision was used followed by either an SSCS approach or a traditional tenotomy of the subscapularis (TDP). LOS, adverse events, physical therapy utilization, and patient satisfaction were collected in the 12 months following RSA. RESULTS: LOS was shorter with the SSCS approach compared to the TDP approach (from 8.2 ± 6.4 days to 15.2 ± 11.9 days; P = 0.04). At 3 months postoperative, the single assessment numeric evaluation score (80 ± 11% vs 70 ± 6%; P = 0.04) and active elevation (130 ± 22° vs 109 ± 24°; P = 0.01) were higher in the SSCS group. The SSCS approach resulted in a net cost savings of $5900 per patient. Postoperative physical therapy, pain levels, and patient satisfaction were comparable in both groups. No immediate intraoperative complications were noted. CONCLUSION: Using a SSCS approach is an option for patients requiring RSA. Overall LOS is minimized compared to a TDP approach with subscapularis tenotomy. The SSCS approach may provide substantial healthcare cost savings, without increasing complication rate or decreasing patient satisfaction.

Supraspinatus Intramuscular Calcified Hematoma or Necrosis Associated with Tendon Tear.

Introduction. Rotator cuff intramuscular calcification is a rare condition usually caused by heterotopic ossification and myositis ossificans. Case Presentation. We describe a patient with voluminous calcified mass entrapped in supraspinatus muscle associated with corresponding tendon tear. Histological examination corresponded to a calcified hematoma or necrosis. Patient was surgically managed with open excision of the calcified hematoma and rotator cuff arthroscopic repair. At 6 months, supraspinatus muscle was healed, and functional outcome was good. Discussion and Conclusion. We hypothesized that supraspinatus intramuscular calcified hematoma was responsible for mechanical stress on the tendon. This association has never been described.