EMG in piriformis syndrome diagnosis: Reliability of peroneal H-reflex according to results obtained after surgery, Botox injection and medical treatment.

Diagnosing piriformis syndrome (PS) throughout the past decades was not that easy, however peroneal H-reflex was proved as reliable test for PS with the change in wave amplitude and delay in conduction as parameters for diagnosis. We interpreted these parameters according to treatment's results carried out for patients presenting clinical PS, aiming to define a threshold value for peroneal H-reflex delay to accurately diagnose. A retrospective mono-centric review of 27 patients, 9 females and 18 males, aged 22-65 years, benefited from peroneal H-reflex test and treated for clinical PS. These patients were classified into 3 groups according to treatment modality they received: 11 patients underwent surgical treatment, 7 patients underwent Botox injections (4 of them benefited from surgery later on) and 9 patients received pharmacological treatment. From 11 operated patients with 4 < delay < 9 ms, 10 had complete improvement and 1 remained in pain. For 7 patients having injection of Botox 100-300 IU, with 5 < delay < 7 ms had a transient recovery, 4 of them have benefited later from surgery, the 3 others reproved pain. Between 9 patients who have declined invasive treatment, 7 patients with 4 < delay < 10 ms didn't demonstrate any improvement after medical treatment and are suspected of PS, 2 others with delay < 4 ms recovered from a non-confirmed PS. A threshold value to diagnose PS was reached through peroneal H-reflex delay ranges, classified as: high with a delay > 5 ms, moderate: 4 < delay < 5 ms and poor: <4 ms.

Periacetabular quadruple osteotomy of the pelvis in older children: computed tomography scan analysis of acetabular retroversion and anterior overcoverage of the hip, preventing femoral acetabular impingement.

The periacetabular quadruple osteotomy of the pelvis (QOP), with the osteotomy of ischial spine to release the sacrospinal ligament, is reserved for older children with low potential of remodeling. Different parameters were studied with computed tomography (CT) scan before (pre-OH) and after surgery (post-OH) and for nonoperated hip (NOH). The study determined an optimal method to avoid retroversion and excessive anterior coverage. Fifteen QOP were performed in 13 patients, ranging in age from 10 to 15 years. The morphology of pelvis was analyzed with a CT scan before the surgery and 2 years after. Pathologies were Legg-Calve-Perthes (seven hips) and dysplasia (eight hips). The two-dimensional exam measured the acetabular index, the coverage, and the version of the acetabulum. The three-dimensional images measured the frontal lateral inclinations of the lips and the sagittal anterior acetabular inclination. The mean anterior acetabular index was 50.4° (NOH), 56° (pre-OH), and 58.7° (post-OH). The posterior acetabular index was 48.5° (NOH), 52.2° (pre-OH), and 40° (post-OH). The anterior coverage angle was 37.1° in (pre-OH), 27.6° (post-OH), and 30.1° (NOH). The posterior coverage was 20.4° (pre-OH), 17.2° (post-OH), and 12.4° (NOH). The acetabular version was 2.1° (pre-OH), 8.3° (post-OH), and 2.5° (NOH). The anterolateral lip inclination was 50.3° (pre-OH), 35.3° (post-OH), and 43.8° (NOH). The posterolateral lip inclination was 56.7° (pre-OH), 43.7° (post-OH), and 55.8° (NOH). The anterior acetabular inclination was 21.3° (pre-OH), 15.6° (post-OH), and 18° (NOH). The QOP enabled significant range of coverage of the hip in adolescents in whom the potential of remodeling is very low. External rotation related to figure-of-four should be omitted, whereas the maneuver to be applied, preventing the anterior impingement and decrease of the posterior coverage, should be performed by placing the acetabular fragment below the iliac bone, with a lateral inclination in the frontal plane similar to a steering wheel movement. This maneuver preserves comparable morphology of the OH with NOH and avoids retroversion with the excessive anterior coverage responsible for pain and early osteoarthritis.

FOREFOOT ADDUCTION IN CHILDREN. Management and Treatment.

Forefoot adduction is a common condition between metatarsus adductus, Z-shaped foot and residual clubfoot. This deformity is located in a pure transverse plane at Lisfranc's joint. Isolated metatarsus adductus is corrected spontaneously for the majority of newborns. In rare uncorrected cases, it could result in Z-shaped foot with a functional hindfoot valgus to equilibrate the resistant metatarsus adductus. As well, in residual clubfoot, recurrent metatarsus adductus varus is observed, usually in children over three years. In flexible metatarsus adductus the treatment is conservative. The surgery is proposed in toddlers and after failure of conservative treatment. Procedures carried out on metatarsals gave good results on short term, but showed a high rate of recurrence and growth disturbance. Osteotomies proximal to the Lisfranc's joint: calcaneo-cuboid fusion, anterior resection of calcaneus, and opening wedge osteotomy of medial cuneiform, gave permanent correction but they act only on one of the sides of deformity. Therefore, the theory of elongated lateral column associated with a shortened medial column is crucial in dealing with this deformity: combining opening wedge osteotomy of cuneiform with closing wedge osteotomy of cuboid described by Jawish et al. in children over 4 years allows ­ in all causes of metatarsus adductus stiffness ­ a lateral shifting of forefoot. Concerning the associated heel's valgus, it is corrected in Z-shaped foot after the associated heel's valgus, it is corrected in Z-shaped foot after the double osteotomy cuneiform/cuboid. However, in complicated treated clubfoot a particular treatment for the posterior tarsal is necessary.

Shortening of the distal ulna to correct ulnar variance in osteoporotic wrist fractures treated with intra-focal pining.

The aim of this study is to correct the ulnar variance in severe osteoporotic wrist fracture treated with intra-focal pining of the distal radius, with shortening osteotomy of the distal ulna. Thirteen patients, 12 females and one male, 61-83 years old, 6-year follow-up, were treated by intra-focal pining (kapandji). When preoperatively the ulnar variance did not return to a normal value comparing to the opposite wrist, a shortening osteotomy of the ulna was performed in one stage, 4 cm proximal to the ulnar head. The fractures healed 6-8 weeks with stability and normal motion: flexion 70°, extension 60° and pronation/supination 140°. There was no pain upon palpation of distal ulna and no sign of radial impingement. Concerning the ulnar variance and starting with nine neutral values at the normal wrist, we obtained eight negative and one neutral ulnar variance after surgery. In four cases of negative variance at normal wrist, we obtained four negative ulnar variances after surgery and two cases of ulnar non-union. In cases of dorsal comminution in wrist fracture with severe osteoporosis, intra-focal pining technique is able to restore all the radiological parameters, but it could not correct the inversion of ulnar variance relative to shortening of the radius. Avoiding secondary interventions, acute shortening osteotomy of the ulna performed is a procedure which allows restoring the ulnar variance without affecting carpal stability and the mobility.

The effect of intra-articular Tenoxicam on knee effusion after arthroscopy.

PURPOSE: NSAIDs and analgesic drugs are used intra-articularly after knee arthroscopy for pain relief. However, synovial effusion is still a common cause of delayed physical therapy. The aim of this study was to demonstrate the beneficial effect of intra-articular injection of Tenoxicam on knee effusion after arthroscopy. METHOD: This was a prospective non-randomized study on 134 patients with a mean age of 36.7 years. Knee arthroscopy on a day-case basis was performed; normal saline was used for irrigation. At the end of the procedure, fluid was aspirated from the knee joint and 20 ml of Tenoxicam diluted with 20 ml of 0.9% normal saline was injected into the knee five minutes before deflation of limb tourniquet. The same surgeon performed clinical examination for knee effusion 14 days postoperatively. RESULTS: Encountered pathologies included meniscal injury, degenerative arthropathy, synovial plica and ACL rupture. Knee effusion developed in 15.7% of the patients, particularly in those with degenerative arthropathy (p = 0.006) and meniscal lesions (p = 0.06). CONCLUSION: Intra-articular Tenoxicam is a simple method for the prevention of postoperative knee effusion. Degenerative arthropathy and meniscal lesions are major risk factors for post arthroscopy knee effusion.

Anatomical, clinical and electrical observations in piriformis syndrome.

BACKGROUND: We provided clinical and electrical descriptions of the piriformis syndrome, contributing to better understanding of the pathogenesis and further diagnostic criteria. METHODS: Between 3550 patients complaining of sciatica, we concluded 26 cases of piriformis syndrome, 15 females, 11 males, mean age 35.37 year-old. We operated 9 patients, 2 to 19 years after the onset of symptoms, 5 had piriformis steroids injection. A dorsolumbar MRI were performed in all cases and a pelvic MRI in 7 patients. The electro-diagnostic test was performed in 13 cases, between them the H reflex of the peroneal nerve was tested 7 times. RESULTS: After a followup 1 to 11 years, for the 17 non operated patients, 3 patients responded to conservative treatment. 6 of the operated had an excellent result, 2 residual minor pain and one failed. 3 new anatomical observations were described with atypical compression of the sciatic nerve by the piriformis muscle. CONCLUSION: While the H reflex test of the tibial nerve did not give common satisfaction in the literature for diagnosis, the H reflex of the peroneal nerve should be given more importance, because it demonstrated in our study more specific sign, with six clinical criteria it contributed to improve the method of diagnosis. The cause of this particular syndrome does not only depend on the relation sciatic nerve-piriformis muscle, but the environmental conditions should be considered with the series of the anatomical anomalies to explain the real cause of this pain.

Opening wedge osteotomy of the first cuneiform for the treatment of hallux valgus.

We performed an opening wedge osteotomy of the first cuneiform for the correction of all degrees of hallux valgus deformities. A wedge-shaped graft maintained the open wedge osteotomy and decreased the metatarsocuneiform joint inclination to correct the main angles of the hallux valgus. This procedure was performed for 101 feet of 63 patients (two men and 61 women). Fifteen feet benefited from a shortening of P1. The average age was 42 (16 to 84) years with a mean follow-up of 7.7 (1.5 to 14.8) years. We evaluated the M1-P1 and the M1-M2 angles, the joint congruency and the position of the lateral sesamoid. The clinical examination was graded by the AOFAS score which includes comprehensive assessment of pain, function and alignment and the subjective assessment of patients. The clinical AOFAS score improved from 35.24 points preoperatively to 86.36 postoperatively and from 33.25 to 88.03 points in severe deformity. The subjective rating was 44.44% excellent, 41.27% good, 9.52% fair and 4.76% poor. The M1-P1 angle improved from 29.38 degrees to 16.28 degrees and the M1-M2 angle from 14.36 degrees to 10.34 degrees . In the 42 severe feet deformity, these angles improved respectively from 45.58 degrees to 19.58 degrees and from 18.51 degrees to 11.16 degrees . This technique allowed an accurate correction of the main angles of hallux valgus with different degrees of deformity and avoided the complications related to different types of osteotomies achieved along the first metatarsal. After a long follow-up, we demonstrated a durable result while 86% of patients proved excellent and good results according to the AOFAS score.

Ganglion cyst of the anterior cruciate ligament in children.

The incidence of ganglion cysts of the anterior cruciate ligament (ACL) has increased significantly since the advent of MRI, but it remains exceptional in children. We report the case of a 7-year-old boy, with an exceptional imaging exam and histological finding of a ganglion cyst. The lesion was at first an MRI finding with a hypointensity signal on T2-weighted sequences of a normal ACL. An arthroscopy was performed that showed a cyst measuring 40 mm filling the intercondylar notch and involving the roof and the edges of the ACL. A cystography confirmed the position of the cyst, which was removed with specific management of the ACL. Histological examination confirmed the absence of mucoid degeneration, which is always observed in adult lesions. We believe that the ganglion cyst of the ACL in children differs in pathogenesis from common degenerative cyst in adults.

[The core decompression of the femoral head for stage I idiopathic osteonecrosis]. / Le forage-biopsie dans les nécroses idiopathiques de la tête fémorale au stade I.

The osteonecrosis of the femoral head is a progressive multi-etiological disease ; its primum movens is circulatory and the pathophysiology is still unexplained. Ficat and Arlet classified this disease into 5 stages from 0 to IV. The progression from one stage to another is inevitable if surgical treatment is not performed early. The MRI is currently the investigation of choice in detecting infraradiological stage I necrosis. The core decompression as proposed by Ficat and Arlet allows to excise the necrotic zone, confirm the histological diagnosis, decompress the intramedullary increased pressure and favor the neovascularization of the femoral head. The aim of this study is to present the mid-term results of the core decompression in a series of 17 hips in 16 patients with an average age of 46 years that were operated upon in stage I idiopathic necrosis of the femoral head, 4 to 6 weeks after the symptoms appeared. The MRI demonstrated the zone of necrosis in 16 hips. The histological examination confirmed the diagnosis of necrosis in 16 hips including the one which was negative on MRI. The Merle d'Aubigné hip score was used for the clinical evaluation and showed to be less than 15 in all hips preoperatively. This score improved to 18 (full value) after a mean follow-up of 8 years, ranging from 3 to 13 years. The X-rays of the operated hips remained normal at the final follow-up in all cases. The very high percentage (100%) of recovery and healing in stage I femoral head necrosis in this series may be explained by the absence of obvious etiological factors (idiopathic necrosis) and moreover by the short delay between the onset of the symptoms and the operative treatment. We believe that the MRI is the examination of choice that should be done early in patients with a painful hip and normal X-rays and that core decompression performed soon is an excellent procedure to treat stage I idiopathic necrosis of the femoral head.

[Value of establishing a registry of hip prostheses in Lebanon]. / Intérêts de la mise en place d'un registre de prothèses de hanche au Liban.

A registry for hip arthroplasty is an excellent method for the surveillance of complications and of short-, mid- and long-term results of a procedure which is becoming increasingly more frequent. Surveillance may lead to improvement of results, reflected by a decrease in the rates of revisions performed after primary surgery, and of health expenses. In addition, registry data can be used for epidemiological studies. This article proposes a financial projection of savings which can be obtained as a result of hip revision rate reductions.

Quadruple and juxta-articular pelvic osteotomy in children using anterior approach: technique and results.

The traditional indications of pelvic osteotomy in children are Salter's osteotomy in young patients and triple osteotomy in older patients. We performed the juxta-articular pelvic osteotomy with a single anterior approach. Our population included a group of young children necessitating a high degree of reorientation. In elder children a quadruple osteotomy of the ischium, pubis, ilium and ischial spine was achieved to release the sacrospinal ligament. Between 1993 and 2003, 30 osteotomies have been carried out on 26 patients. The mean age was 6.7 years, 10 patients were younger than 5 years, with 6 years of follow-up. The indications included acetabular dysplasia (15 cases), Perthes disease (14 cases) and one caput valgum. When compared with preoperative clinical examination, the postoperative flexion was decreased by 14 degrees, extension increased by 7 degrees, external rotation increased by 5 degrees, internal rotation decreased by 5 degrees. Radiographic assessment demonstrated an average angle of correction by 20 degrees for the acetabular angle of Sharp, 32 degrees for the center edge angle and 18 degrees for the slope of sourcil. We concluded that lateral coverage must be achieved in a frontal plan, avoiding the figure-of-four maneuvers and displacement in a transverse plan. Despite the significant reorientation of the acetabulum, we did not observe excessive external rotation. The quadruple osteotomy allowed important acetabular displacement in older patients. The single approach avoided prone position and permitted a simpler postoperative management.

Three-dimensional computed tomography analysis and anteversion study after periacetabular osteotomy of pelvis in children.

PURPOSE: Three-dimensional computed tomography (CT) is the method of choice in understanding the morphological changes after periacetabular osteotomy in children. We studied different parameters and compared aspects of operated hip (OH) with non-operated hip (NOH) to define the maneuver that promotes normalization of the hip during repositioning of the acetabulum. METHODS: A total of 22 patients with 25 OHs underwent CT control scans an average of 4 years after surgery. The patients, with a mean age of 6.8 years, had either Legg-Calvé-Perthes disease (12 cases) or dysplasia (10 cases).The measurements included the anterior and posterior coverage angles of the hip and version of the acetabulum on axial CT views. The 3D reconstructed images measured the inclination of the antero- and postero-lateral lips, the external rotation and the anterior inclination of the acetabulum. RESULTS: The mean anterior coverage angle was 27 degrees for OHs, 31 degrees for NOHs, and 12 degrees versus 10.3 degrees for the posterior coverage angle. Acetabular anteversion was 2 degrees for OHs (6.3 degrees in the dysplastic OHs) and 6 degrees for NOHs. The mean angle of inclination of the antero-lateral lip was 37 degrees for OHs, 47 degrees for NOHs, and the postero-lateral lip inclination was 56 degrees for OHs and 67 degrees for NOHs. Inferior 3D views showed a mean internal acetabular rotation of 1.5 degrees (4.8 degrees in the dysplastic OH), 3 degrees for NOH. The anterior acetabular inclination angle measured with lateral 3D views was 6 degrees for OHs, 11 degrees for NOHs. CONCLUSION: Our analysis demonstrated a mean anteversion of the acetabulum despite normalization of the anterior coverage of the hip, particularly in the dysplastic group, in which the osteotomized fragments had anteversion superior to NOH. The unexpected external rotation used to improve anterior coverage of a coax magna in Legg-Calvé-Perthes disease was responsible for the retroversion and the decrease of the posterior coverage.