Exercise testing criteria to diagnose lower extremity peripheral artery disease assessed by computed-tomography angiography.

BACKGROUND: The sensitivity and specificity of exercise testing have never been studied simultaneously against an objective quantification of arterial stenosis. Aims were to define the sensitivity and specificity of several exercise tests to detect peripheral artery disease (PAD), and to assess whether or not defined criteria defined in patients suspected of having a PAD show a difference dependent on the resting ABI. METHODS: In this prospective study, consecutive patients with exertional limb pain referred to our vascular center were included. All patients had an ABI, a treadmill exercise-oximetry test, a second treadmill test (both 10% slope; 3.2km/h speed) with post-exercise pressures, and a computed-tomography-angiography (CTA). The receiver-operating-characteristic curve was used to define a cut-off point corresponding to the best area under the curve (AUC; [CI95%]) to detect arterial stenosis ≥50% as determined by the CTA. RESULTS: Sixty-three patients (61+/-11 years-old) were included. Similar AUCs from 0.72[0.63-0.79] to 0.83[0.75-0.89] were found for the different tests in the overall population. To detect arterial stenosis ≥50%, cut-off values of ABI, post-exercise ABI, post-exercise ABI decrease, post-exercise ankle pressure decrease, and distal delta from rest oxygen pressure (DROP) index were ≤0.91, ≤0.52, ≥43%, ≥20mmHg and ≤-15mmHg, respectively (p<0.01). In the subset of patients with an ABI >0.91, cut-off values of post-exercise ABI decrease (AUC = 0.67[0.53-0.78]), and DROP (AUC = 0.67[0.53-0.78]) were ≥18.5%, and ≤-15mmHg respectively (p<0.05). CONCLUSION: Resting ABI is as accurate as exercise testing in patients with exertional limb pain. Specific exercise testing cut-off values should be used in patients with normal ABI to diagnose PAD.

A combined tension-band braided polyester and suture button technique is a valuable treatment alternative for transverse patellar fractures in athletes.

PURPOSE: Transverse patellar fractures (TPFs) are uncommon in athletes, and their treatment can be challenging. Stable fixation is commonly achieved by compression screw fixation and stainless steel cerclage wire, but this technique can be associated with complications like nonunion, infection and the need for early hardware removal. We used a combined tension-band (figure-of-eight) braided polyester and suture button technique to treat four athletes who presented with transverse patellar fractures. This technique has shown to be a valuable alternative to the classic technique and allows for adequate fracture compression, stability and union in TPF. METHODS: Using a tension-band braided polyester and suture button technique (Arthrex FibreTapeR&TightRopeR), we treated four athletes with transverse patellar fractures from September 2015 till January 2017. The polyester was looped over the four suture button fixation points and tensioned in a figure-of-eight fashion. The average age of the athletes was 26 years (range 17-36). Follow-up ranged from 5 to 21 months. All four patients were treated using the same surgical technique (minimally invasive surgery) with the same postoperative recovery and the same physiotherapy protocol. RESULTS: Full recovery using suture button adjustable loop fixation device was obtained in all four cases within 3 months after surgery, with fracture healing confirmed on postoperative radiographs. No patients required hardware removal. Potential problems with this technique can include bony tunnel malpositioning or soft tissue interpositioning underneath the suture buttons. CONCLUSION: The combination of a suture button fixation and a braided polyester tension-band technique has shown to be a valuable alternative to the fracture management of transverse patella fractures in athletes. This results in fracture healing, low risk of complications and no need for hardware removal.

Endoscopic surgery in athletes with a symptomatic calcaneal lipoma.

PURPOSE: This study shows that endoscopy is an effective treatment modality for athletes with a symptomatic calcaneal lipoma. METHODS: Between 2013 and 2016, five professional athletes with symptomatic calcaneal lipoma underwent endoscopic-assisted curettage and bone graft treatment. Lipoma size was measured by magnetic resonance imaging (MRI) and rated using the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS). All athletes were followed up for 12 months postoperatively and monitored on return to previous activity level. RESULTS: The mean ankle-hindfoot scale score improved from a preoperative 71.3 +/-3.9 points (median 67-81) to a postoperative 97.8 +/-3.4 points (median 89-100). Radiological assessment revealed no recurrence or pathologic fracture, with adequate bone fill-up in all 5 cases. All athletes returned to their previous level of activity within 8 weeks of surgery (mean period 7.2 weeks, median 5-8 weeks). CONCLUSION: Endoscopic surgery can be used as a valid treatment tool for athletes with a calcaneal lipoma. It allows for a safe and early return to sports activities and minimises risk for recurrence and pathological fracture after initial return to play. LEVEL OF EVIDENCE: IV.

Radiation-induced pancreatitis: search for the neoplasm!

The management of a patient with a post-radiation pancreatitis is reported. Several biopsies and imaging failed to diagnose the radiation-induced carcinoma revealed during emergency laparotomy. This diagnosis must be kept in mind, and repeated biopsies are necessary.

[Meniscus and cartilaginous lesions. Influence of the delay between ACL injury and ligament reconstruction in 40-year-old patients]. / Influence sur les lésions méniscocartilagineuses du délai accident-reconstruction du ligament croisé antérieur chez les patients de plus de 40 ans.

PURPOSE OF THE STUDY: Anterior cruciate ligament (ACL) reconstruction is increasingly proposed for patients aged over 40 years. We report a retrospective analysis of a consecutive series of middle-aged patients who underwent ACL reconstruction surgery in order to analyze the development of meniscal and cartilage lesions and ascertain short-term outcome. MATERIAL AND METHODS: Thirty-five patients aged over 40 years (mean 46.1 years) underwent hamstring ACL reconstruction, 19 for persistent instability after functional treatment and 16 after a recent tear in patients who wanted to resume their sports activities. Mean follow-up was 25 months. The IKDC 1993 score was noted as was the Arpege score for sports activity and Telos at 15 and 25kg. RESULTS: At the last follow-up, the IKDC score was A or B in 85% of patients. Among the first intention ligamentoplasties, 94% were scored A or B at last follow-up and all had a single leg jump test greater than 76%. Among patients operated on after failure of functional treatment, 79% were scored A or B (p>0.05) and 32% had a single leg jump test less than 75% (p<0.05). Intraoperative discovery of meniscal or cartilage damage was statistically less significant in first intention patients than after failure of functional treatment. Somewhat less than half of the active and motivated patients aged over 40 years who underwent a first intention operation were unable to resume their sports activities at the same level. However, patients who underwent ACL repair after failure of functional treatment unexpectedly recovered sports activities after an interruption of several months or even years. DISCUSSION: Age is not a barrier to ACL reconstruction. The time from injury to surgery is a prognostic factor predictive of meniscal and osteochondral damage. Early repair of the ACL preserves the knee's meniscal and cartilaginous stock. For active motivated patients aged over 40 years, who undergo a first-intention procedure, resumption of sports activities at the same level cannot be guaranteed after ACL. However, for patients who undergo surgery after failure of functional treatment, ACL reconstruction not only eliminates the troublesome laxity but also enables resumption of sports activities even after several months or years of interruption.

[Arthroscopic Management of the Stiff Elbow.] / Traitement arthroscopique des raideurs du coude.

Elbow stifness has diverse etiologies, the most common being post-trauma. It appears that both arthroscopic and open techniques can achieve satisfactory results when employed properly. Their use is dictated both by the surgeon's level of expertise and an accurate preoperative assessment. When the release is done arthroscopically, collateral ligament stability is not compromised and morbidity from surgical dissection is minimized. The technique of arthroscopic release is described with all steps and difficulties. Arthroscopic capsular release is a technically demanding procedure that requires meticulous attention to detail and should only be attempted by surgeons with extensive experience in elbow arthroscopy.

[Arthroscopic repair of full-thickness tears of the rotator cuff.] / Réparation arthroscopique des ruptures transfixiantes de la coiffe.

INTRODUCTION: Shoulder arthroscopy was only at first a surgical technique for subacromial decompression and has been progressively extended to the cuff repairs. This surgery remains nevertheless difficult and requires to be described exactly. A multicenter study of the French Arthroscopic Society allowed to analyse and to underline the quality of the clinical and anatomical results. SURGICAL TECHNIQUE: The technique is described exactly as well as the necessary material. Repair will be adapted to the size and the location of the tear. The technical skill should be simple, effective and reproducible to obtain the best anatomical result. RESULTS: The Constant score improved from an average 46.3 (13.4) to 82.7 (+/-10.3) at the last follow-up, with 62% of patients' symptom free. Strength improved from 5.8 (+/-3.7) to 13.6 (+/-5.4). Ninety-four percent of the results were rated as excellent or good (Constant score>65). A watertight repair was found in 74.1% of the cases. DISCUSSION: Numerous correlations allow to confirm the results found in the literature: the healing of the cuff improves global functional results even when the tear is massive; anatomical result depends on the size of the initial tear; preoperative fatty degeneration is an important predictive factor; the healing of the cuff is related to the age. The quality of the results, the evolution of the material, the simplification and the codification of the surgical technique make it an accessible, effective reproducible surgery.

[Arthroscopic repair of full-thickness tears of the rotator cuff]. / Réparation arthroscopique des ruptures transfixiantes de la coiffe.

INTRODUCTION: Shoulder arthroscopy was only at first a surgical technique for subacromial decompression and has been progressively extended to the cuff repairs. This surgery remains nevertheless difficult and requires to be described exactly. A multicenter study of the French Arthroscopic Society allowed to analyse and to underline the quality of the clinical and anatomical results. SURGICAL TECHNIQUE: The technique is described exactly as well as the necessary material. Repair will be adapted to the size and the location of the tear. The technical skill should be simple, effective and reproducible to obtain the best anatomical result. RESULTS: The Constant score improved from an average 46.3 (13.4) to 82.7 (+/- 10.3) at the last follow-up, with 62% of patients' symptom free. Strength improved from 5.8 (+/- 3.7) to 13.6 (+/- 5.4). Ninety-four percent of the results were rated as excellent or good (Constant score >65). A watertight repair was found in 74.1% of the cases. DISCUSSION: Numerous correlations allow to confirm the results found in the literature: the healing of the cuff improves global functional results even when the tear is massive; anatomical result depends on the size of the initial tear; preoperative fatty degeneration is an important predictive factor; the healing of the cuff is related to the age. The quality of the results, the evolution of the material, the simplification and the codification of the surgical technique make it an accessible, effective reproducible surgery.

[Arthroscopic management of the stiff elbow]. / Traitement arthroscopique des raideurs du coude.

Elbow stifness has diverse etiologies, the most common being post-trauma. It appears that both arthroscopic and open techniques can achieve satisfactory results when employed properly. Their use is dictated both by the surgeon's level of expertise and an accurate preoperative assessment. When the release is done arthroscopically, collateral ligament stability is not compromised and morbidity from surgical dissection is minimized. The technique of arthroscopic release is described with all steps and difficulties. Arthroscopic capsular release is a technically demanding procedure that requires meticulous attention to detail and should only be attempted by surgeons with extensive experience in elbow arthroscopy.

[Arthroscopic repair of full-thickness cuff tears: a multicentric retrospective study of 576 cases with anatomical assessment]. / Réparation arthroscopique des ruptures transfixiantes de la coiffe des rotateurs: étude rétrospective multicentrique de 576 cas avec contrôle de la cicatrisation.

PURPOSE OF THE STUDY: Totally arthroscopic repair of rotator cuff tears is now common practice. The techniques used were evaluated by a retrospective multicentric analysis conducted by the French Society of Arthroscopy. MATERIAL AND METHODS: The series was limited to arthroscopic repair of full thickness tears of the supraspinatus or infraspinatus evaluated using the Constant score and arthro-MRI or arthroscan performed with at least one year follow-up. Data were processed with SPSS 10. The series included 576 patients who underwent surgery between January 2001 and June 2003. Mean patient age was 57.7 years; 52% were men and 60% were manual laborers. The mean preoperative Constant score was 46.4 +/- 13.4/100. The tear was limited to the supraspinatus in 69% of shoulders, with extension to the upper third of the infraspinatus in 23.5% and the entire infraspinatus in 7.5%. The supraspinatus tear was distal in 41.7% of shoulders, intermediary in 44% and retracted in 14.3%. Fatty degeneration of the supraspinatus was noted grade 0 in 60%, 1 in 27%, 2 in 11% and 3 in 2%. Arthroscopic repair was performed in all cases, with locoregional anesthesia in 60.9%. Bioresorbable implants were used in 33% and metallic implants in 62.1%. Acromioplasty was performed in 92.7% and capsulotomy in 14.9%. RESULTS: On average, the subjective outcome was scored 8.89/10. The Constant score improved from 46.3 +/- 13.4 to 82.7 +/- 10.3 with 62% having a strictly pain free shoulder. Muscle force improved from 5.8 +/- 3.7 to 13.6 +/- 5.4. Outcome was excellent in 94% of shoulders at 18.5 months mean follow-up. The complication rate in this series was 6.2% with 3.1% prolonged stiffness, 2.7% reflex dystrophy, 0.2% infection, and 0.2% anchor migration. The cuff was considered normal in 55.7% of shoulders with an intratendon addition image in 19%, i.e. 74.7% of non-ruptured cuffs. Minimal loss of integrity was noted in 9.5% and was marked in 15.7%, i.e. 25.2% iterative tears.ANATOMOCLINICAL CORRELATIONS: The Constant score was strongly correlated with rotator cuff integrity (p<0001). This correlation was also found for force (p<0001), motion (0.01) and activity (0.04), but not for pain. The clinical outcome was correlated with extension, retraction, intrasubstance tear, and fatty degeneration of the lesion preoperatively. Anatomic results were statistically less favorable for tears which were older, extensive, retracted or associated with fatty degeneration. Age was correlated with extent of the initial tear and also with less favorable anatomic and clinical outcome. Occupational accidents were correlated with less favorable clinical outcome. CONCLUSION: Functional improvement after healing is a strong argument for repair. Arthroscopy has the advantage of combining a low complication rate with good clinical and anatomic results. Age is correlated with functional outcome and healing, but is not a contraindication.

[Sudden deafness: different pathologies and results of treatment by normovolemic hemodilution]. / Surdités de survenue brutale: différentes pathologies et résultats d'un traitement par hémodilution normovolémique.

The authors report 75 cases (including 4 children) treated between 1983 and 1988 by normovolemic hemodilution, corticoids and vasodilators for deafness of various origins. This treatment has an action in deafness of brutal occurrence and all the more so when applied early. The youngest subjects, with viral disorders and the oldest with vascular disorders receive less favourable prognoses. The main risk factors found are represented by a previous vascular and otological history. When hemodilution fails, it is best to associate hyperbaric oxygen therapy rapidly.