[Non-traumatic fractures at the end of a pregnancy: are there always of osteoporotic origin]. / Fractures non traumatiques en fin de grossesse: s'agit-il toujours d'une ostéoporose? A propos de deux cas.

Pregnancy-associated osteoporosis usually appears during the first pregnancy and does not affect the followings. We report two cases where non-traumatic fractures have been diagnosed shortly after delivery of second pregnancies. Wide investigations could not find a cause of secondary osteoporosis. In the first case we came to the diagnosis of pregnancy-associated osteoporosis and an intravenous treatment of ibandronate has been prescribed. In the second case the bone mineral density (BMD) being almost normal and the localisation of the fracture being atypical, we concluded to a fracture of non-osteoporotic origin, probably due to mechanical stress during pregnancy. No therapy against osteoporosis has been prescribed.

[Imaging in osteoarthritis]. / Imagerie et arthrose.

Plain radiography remains useful for the diagnosis of osteoarthritis, even if it is not always essential. It is moreover poorly correlated with symptoms, as it reflects rather the accumulation of damage then active processes. Similarly, it is a poor indicator of the progression of osteoarthritis. Modem imaging, particularly MRI, has allowed us to understand better the evolving processes, demonstrating a good correlation with symptoms and a better predictive value of clinical course. It has gradually replaced standard radiography in the study because it directly demonstrates sequelae and the active processes in all the structures of the joint. It remains clinically indicated only to exclude an alternative diagnosis or to determine a possible complication of osteoarthritis.

Direct magnetic resonance arthrography of the knee: utility of axial traction.

The purpose of this study was to determine the impact of axial traction during acquisition of direct magnetic resonance (MR) arthrography examination of the knee in terms of joint space width and amount of contrast material between the cartilage surfaces. Direct knee MR arthrography was performed in 11 patients on a 3-T MR imaging unit using a T1-weighted isotropic gradient echo sequence in a coronal plane with and without axial traction of 15 kg. Joint space widths were measured at the level of the medial and the lateral femorotibial joint with and without traction. The amount of contrast material in the medial and lateral femorotibial joint was assessed independently by two musculoskeletal radiologists in a semiquantitative manner using three grades ('absence of surface visualization, 'partial surface visualization or 'complete surface visualization'). With traction, joint space width increased significantly at the lateral femorotibial compartment (mean = 0.55 mm, p = 0.0105) and at the medial femorotibial compartment (mean = 0.4 mm, p = 0.0124). There was a trend towards an increased amount of contrast material in the femorotibial compartment with axial traction. Direct MR arthrography of the knee with axial traction showed a slight and significant increase of the width of the femorotibial compartment with a trend towards more contrast material between the articular cartilage surfaces.

[Inguinal pain in sportmen: clinical and radiological examinations]. / Douleurs inguinales chez le sportif: examen clinique et radiologique.

Pain of the inguinal region is a frequent but difficult diagnostic problem. It may be induced by accidents, overload due to sports or profession as well as daily life activities. Numerous anatomic structures of the inguinal or hip region may be injured, but one should also think about adjacent structures as the bowel, uro-genital system, spine and nerves. The goal of this article is to describe which clinical and imaging parameters allow to establish a correct diagnosis for each patient.

[Femoro-acetabular impingement]. / Le conflit fémoro-acétabulaire.

Femur-acetabular impingement is a recently discovered etiology of early hip osteoarthritis. Patient history and clinical examination allow to make the diagnosis, whereas the radiological exams allow to find the etiology of impingement. Impingement is related to morphological alterations of the acetabular rim and/or proximal femur, leading to an abnormal contact between the articular components. The localisation of the abnormal morphology determines the type of impingement and the resulting articular damages. Because of the increasing risk of chondral lesions, only an early treatment may eventually improve the prognosis of the hip joint. If primary conservative treatment is unsuccessful in confirmed impingement cases, open or arthroscopic surgical treatment is indicated.

Spontaneous reduction of a traumatic L2-L3 subluxation without fracture in a 14-year-old boy.

OBJECTIVE: To report a rare case of lumbar vertebral subluxation associated with spontaneous reduction in an adolescent treated conservatively. CLINICAL PRESENTATION AND INTERVENTION: A 14-year-old male victim of a snowboard accident, which caused a lumbar spinal injury, was referred to the emergency room with significant lumbar pain. Neurologic examination was normal. Radiographic assessment at admission showed a unilateral left lateral subluxation of the L2-L3 vertebrae without associated fractures. These findings were confirmed by CT scan and a surgical management was decided. The preoperative MRI performed 24 h after the accident, however, revealed the spontaneous reduction of the subluxation, and an associated tear of the quadratus lumborum and the psoas muscles on the right side at the level of L2, L3 and L4. Following these findings conservative treatment with a plaster brace for 2 months was carried out. The brace was removed after 2 months. The patient had no pain and the range of motion of his lumbar spine was normal. Three months after injury, sports activities were resumed. At follow-up of 24 months, the patient was free of pain and radiographs showed a right positional bending without rotational or translation anomaly. CONCLUSION: To date, this is the first case of subluxation without fracture in a child, presenting without neurological deficit and where spontaneous reduction occurred. In this case, conservative treatment was effective and the outcome at 2-year follow-up was excellent.

[Clinical and radiological aspects of femoro-acetabular impingement]. / Aspects cliniques et radiologiques du conflit fémoro-acétabulaire.

Femoro-acetabular impingement is an etiology of early osteoarthritis. It is a dynamic theory of development of arthritis due to bony deformations of the acetabulum or the proximal femur. The impingement is diagnosed clinically by the impingement and apprehension tests. The realisation of reproducible and technically irreproachable standard X-Rays is of first importance to detect the subtle but present signs of impingement. The MR arthrography is the best exam for detection of intra-articular pathologies with radial sequences allowing to establish a precise topography of the lesions. The treatment is most of the time surgical to avoid progression of cartilage lesions, either by an open surgical dislocation or arthroscopically for selected cases.

[Percutaneous sacroplasty]. / La sacroplastie percutanée.

Sacral insufficiency fracture is a debilitating injury for which no active treatment is currently available. It frequently causes significant pain and limits activities of daily living in patients with osteoporosis. Percutaneous vertebroplasty is a common procedure to alleviate the pain associated with thoracic and lumbar vertebral compression fractures. The sacral percutaneous cimentoplasty procedure (sacroplasty) has recently been introduced as an alternative to medical management of osteoporotic sacral insufficiency fractures. The purpose of this article is to illustrate the effectiveness and the utility of percutaneous sacroplasty in this kind of pathology and to show how this procedure can provide symptom relief without having major complications.

Tuberculosis of the greater trochanter. Report of four cases.

OBJECTIVE: To present four cases of tuberculosis of the greater trochanter. CASE PRESENTATION AND INTERVENTION: The four cases (3 females and 1 male), aged 45-70 years, presented with mechanical pain in the trochanteric area associated with progressive swelling in the 3 female patients in whom mobility was also restricted. X-ray revealed a mass in 2 females; CT scan and MRI exhibited an abscess in the 3 females. Histological and bacteriological examinations showed Mycobacterium bovis in the 3 females and M. tuberculosis in the male. In the females, tritherapy and surgery were performed, while in the male quadritherapy and surgery. All the patients recovered and were followed up for 4-9 years. CONCLUSION: These cases show that both chemotherapy and surgery must be synergic if tuberculosis is diagnosed and an abscess is confirmed by imaging.

Modified triangular posterior osteosynthesis of unstable sacrum fracture.

We report preliminary results for unstable sacral fractures treated with a modified posterior triangular osteosynthesis. Seven patients were admitted to our trauma center with an unstable sacral fracture. The average age was 31 years (22-41). There were four vertical shear lesions of the pelvis and three transverse fracture of the upper sacrum. The vertical shear injuries were initially treated with an anterior external fixator inserted at the time of admission. Definitive surgery was performed at a mean time of 9 days after trauma. The operation consisted in a posterior fixation combining a vertebropelvic distraction osteosynthesis with pedicle screws and a rod system, whereby the transverse fixation was obtained using a 6 mm rod as a cross-link between the two main rods. Late displacement of the posterior pelvis or fracture was measured on X-ray films according to the criteria of Henderson. The patients were followed-up for a minimum time of 12 months. Four patients who presented with a pre-operative perineal neurological impairment made a complete recovery. No iatrogenic nerve injury was reported. One case of deep infection was managed successfully with surgical debridement and local antibiotics. All patients complained of symptoms related to the prominence of the iliac screws. The metalwork was removed in all cases after healing of the fracture, at a mean time of 4.3 months after surgery. No loss of reduction of fracture was seen at final radiological follow-up. The preliminary results are promising. The fixation is sufficiently stable to allow an immediate progressive weight-bearing, and safe nursing care in polytrauma cases. The only problem seems to be related to prominent heads of the distal screws.

SAPHO syndrome masquerading as metastatic bone disease.

A 46-year-old woman who had had a right mastectomy for breast carcinoma a month before underwent bone scintigraphy. The examination revealed multiple pelvic, vertebral and sternal hot spots suggestive of bone metastases. Standard X-rays and CT confirmed the presence of bony lesions but they were not typical of bone metastases. As the radiographic appearance was reminiscent of SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis), bone biopsies were performed. Histology showed fibrosis and hyperostosis but no tumour cells. On further questioning, the patient revealed she had had palmar pustulosis and sacroiliitis some years earlier. The purpose of the case report is to show that accurate diagnosis of SAPHO syndrome requires careful clinical and radiological examinations.

[Percutaneous vertebroplasty]. / Vertébroplastie par voie percutanée.

Although vertebroplasty was initially a treatment of vertebral haemangioma or metastases, this procedure is now frequent option to the treatment of osteoporotic vertebral fractures. In this review article, we will discuss the indication, the techniques and the follow-up of the vertebroplasty. This is a risky procedure, which should be performed by experimented physicians working with high-resolution fluoroscopic equipments, by biplane fluoroscopy, to reduce the risk and irradiation to the patient. According to the available follow-up studies, there is clear evidence of a strong improvement of quality of life after vertebroplasty by rapid decreasing of back pain at least during the first six months. Other new studies will analyze the long-term follow-up after vertebroplasty.

[Interventional neuroradiologic procedures]. / Neuroangiographie thérapeutique.

Intracranial aneurysms, cervical carotid stenosis and acute cerebral ischemia constitute the three main and more frequent diseases in which the endovascular approach is considered a valuable alternative to the surgical or pharmacologic treatment. With the introduction of balloon assistance techniques, even intracranial large neck aneurysms can be currently suitable to endovascular treatment. Stent angioplasty is widely used in whole Europe in the treatment of cervical carotid artery stenosis. Mechanical endovascular embolectomy techniques are actually available to be used alone or in combination with pharmacologic thrombolysis in the treatment of acute cerebral ischemia. This article discuss on the new technical possibilities concerning the endovascular approach in these aforementioned diseases.

[Clinical evaluation of rheumatoid arthritis in practice]. / Evaluation clinique d'une polyarthrite rhumatoïde en pratique quotidienne.

Clinical evaluation is an integral part of medical practice. However, recent data have demonstrated that a systematic and standardized evaluation modifies the prognosis of our rheumatoid arthritis patients. The systematic use of activity indexes allows us to better appreciate the needs of our patients and the necessity to optimize and intensifie treatment. Likewise, auto-evaluations tools bring useful information to patient management.

[Interest of magnetic resonance imaging in rheumatoid arthritis]. / Intérêt de l'imagerie par résonance magnétique dans l'évaluation de la polyarthrite rhumatoïde.

Magnetic Resonance Imaging (MRI) is the best imaging method in early detection and management of rheumatoid arthritis (RA). There are other imaging methods available as ultrasound, scintigraphy, computed tomography and plain radiography for imaging RA but MRI provides the best sensitivity in detecting inflammatory changes in the joints. MRI shows the best intra and interobserver reliability and low variation between repetitive examinations. MRI has shown the best visualisation and the greater sensitivity to detect erosion in early RA, compared to standard radiography. The use of a contrast agent further increases the sensitivity in detecting erosions and differentiate synovial proliferation from fluid collections. Otherwise, intraossous cyst, tenosynovitis, bone marrow edema, that are concomitant manifestations of the disease, are best imaged by MRI. MRI assists in the early detection of rheumatoid arthritis, which allows earlier initiation of treatment.

[Rheumatoid arthritis and pregnancy]. / Polyarthrite rhumatoïde et grossesse.

Rheumatoid arthritis occurs frequently in women in childbearing years. With the improvement of the treatments, more patients with rheumatoid arthritis consider a pregnancy. Close co-operation between the physician and the obstetrician caring for the mother and the foetus is necessary. The disease should be well controlled at the time of the conception, although an amelioration of rheumatoid arthritis occurs in about 75% of pregnancies, in the first trimester. Some medications can be used during pregnancy and lactation. There is no indication of any adverse effects of rheumatoid arthritis on pregnancy outcome. The mother needs to be followed up regularly after delivery because of the high risk of post-partum flare.

Posttraumatic pseudolipoma: MRI appearances.

The goal of this study was to describe the MRI characteristics of posttraumatic pseudolipomas. Ten patients with previous history of blunt trauma or local surgery were investigated with MRI at the level of their deformity. The etiology was blunt trauma in eight patients and postoperative trauma in two. For all patients medical documentation, in the form of clinical history and physical examination, confirmed that a visible hematoma was present acutely at the same location following the injury and that the contour deformity subsequently appeared. All patients underwent liposuction. Preoperative bilateral MRI examinations were performed on all patients. The mean clinical follow-up was 17.8 months. MRI examinations were interpreted in consensus by two experienced musculoskeletal radiologists with attention to fatty extension (subcutaneous fatty thickness and anatomical extension), asymmetry compared with the asymptomatic side, the presence or absence of fibrous septae or nonfatty components, and patterns of contrast enhancement. Ten posttraumatic pseudolipomas were identified. Clinically, they showed as subcutaneous masses with the consistency of normal adipose tissue. Their locations were the abdomen (n=1), hip (n=1), the upper thigh (n=6), the knee (n=1), and the ankle (n=1). On MRI examinations, using the contralateral side as a control, pseudolipomas appeared as focal fatty masses without a capsule or contrast enhancement. Posttraumatic pseudolipomas may develop at a site of blunt trauma or surgical procedures often antedated by a soft tissue hematoma. Characteristic MRI findings are unencapsulated subcutaneous fatty masses without contrast enhancement.

Effects of the posterior cruciate ligament reconstruction on the biomechanics of the knee joint: a finite element analysis.

BACKGROUND: Previous experimental studies have been conducted to evaluate the biomechanical effects of posterior cruciate ligament reconstruction; but no consensus has been reached on the preferred method of reconstruction. METHODS: The 3D finite element mesh of a knee joint was reconstructed from computed tomography and magnetic resonance images. The ligaments were considered as hyperelastic materials. The tibiofemoral and patellofemoral joints were modeled with large sliding contact elements. The 3D model was used to simulate knee flexion from 0 degrees to 90 degrees in four cases: a knee with a "native" posterior cruciate ligament, a resected posterior cruciate ligament, a reconstructed single graft posterior cruciate ligament, and a reconstructed double graft posterior cruciate ligament. FINDINGS: A resected posterior cruciate ligament induced high compressive forces in the medial tibiofemoral and patellofemoral compartments. The pressures generated in the tibiofemoral and patellofemoral compartments were nearly the same for the two reconstruction techniques (single graft and double graft). The single graft resulted in lower tensile stresses inside the graft than for the double graft. INTERPRETATION: Firstly, a resected posterior cruciate ligament should be replaced to avoid excessive compressive forces, which are a source of cartilage degeneration. Secondly, the two types of posterior cruciate ligament reconstruction techniques partially restored the biomechanics of the knee in flexion, e.g. contact pressures were restored for pure flexion of the knee. The reconstruction techniques therefore partially restore the biomechanics of the knee in flexion. A double graft reconstruction is subjected to the highest tensile stresses.

[Imaging of tumors and tumor-like diseases of the hand]. / Imagerie des tumeurs et des lésions d'apparence tumorale de la main.

Tumors and tumor-like lesions of the hand are more frequently benign lesions. Plain film X-rays must be obtained in all patients since they are extensive and panoramic. Ultrasound can accurately assess the internal structure of the mass and its relation with adjacent nerves and vessels. MRI is particularly sensitive to bone marrow and is highly effective in characterizing a wide variety of soft tissue conditions. However, CT remains the method of choice for evaluating bone involvement of soft tissue tumors and small bone tumors such as osteoid oteoma. Where a malignant tumor is considered, thoraco-abdominal and/or bone scintigraphy are essential to evaluate the presence of metastatic lesions.