Osteoid osteoma distal to a hip arthroplasty.

The authors report a case of osteoid osteoma distal to a hip prosthesis in a 56-year-old patient. This rare association was difficult to diagnose; at first, the pain seemed to be of mechanical origin, suggesting a delayed painful reaction to the prosthesis. The results of bone scan as well as the CT scan ones helped orient the diagnosis. Excision biopsy, using bone trephining, completed by an iliac bone auto-graft resulted in a cure with no residual instability of the prosthesis above the tumor. Bone scan with radio-isotopes to localize the lesion was particularly helpful in this instance to secure the final diagnosis.

Iliac bone-block autograft for posterior shoulder instability.

INTRODUCTION: Posterior shoulder instability is a rare condition, representing only 4% of all shoulder-joint instabilities. Numerous surgical techniques are used to treat it when conservative functional treatment proves to be insufficient. This retrospective study relates to 8 patients, presenting recurrent posterior shoulder instability, all treated with a posterior iliac bone-block procedure. The results were assessed both clinically and with contemporary imaging techniques. MATERIALS AND METHODS: A unique identical surgical technique was used in all these cases including a posterior deltoid head detachment, an infraspinatus muscle dissociation and a bone-block positioning intended to extend and enlarge the glenoid cavity rather than to act as an actual block. Seven of these 8 cases were posttraumatic (including 2 with a concomitant congenital hyperlaxity past history) and the non-traumatic 1 was secondary to an epileptic seizure episode. All the patients had a typical posterior shoulder instability clinical presentation in the form of recurrent true dislocation incidents. In 6 cases, imaging revealed lesions of the humeral head or the glenoid cavity. These lesions were displacement-related anterior impaction defects of the humeral head (McLaughlin lesion) and/or a fracture (or erosion) of the posterior glenoid rim. Mean postoperative follow-up was 34 months. RESULTS: No cases of postoperative suprascapular nerve deficit were observed. All patients recovered normal joint range of motion in abduction and anterior elevation; in 3 patients, however, external rotation ended up being limited by an average 20 compared to the opposite side. The mean Constant score was 96.25 points and the mean Duplay score 90. Only 4 patients were able to return to their preoperative sports activity level. Three required an additional procedure, 2 for hardware removal and 1 for posterior deltoid repair, which all lead to an uneventful evolution. Imaging at follow-up (X-ray or CT) did not show any instance of bone-block pseudoarthrosis or osteolysis nor did it exhibit glenohumeral early degenerative changes. In all, at a mean 3 years' follow-up, the present series showed satisfactory results in 80% of cases. A literature review found comparable results for bone-block stabilization procedures. No recurrences of instability are reported with this technique, the main difficulty of which residing in the correct positioning of the bone-block. The stabilizing efficacy and low subsequent arthritic changes of the iliac posterior bone-block graft procedure seem thus confirmed by these encouraging results. DISCUSSION AND CONCLUSION: The iliac posterior shoulder bone-block is effective in managing instances of involuntary posterior shoulder instability. A review of the literature confirmed these satisfactory results in terms of non-recurrence, pain relief and function recovery with this technique; the main difficulties of this technique remains in the correct positioning of the bone-block and the proper orientation of the fixation screws.

Knee MR-arthrography in assessment of meniscal and chondral lesions.

INTRODUCTION: No study, so far in France, has investigated the diagnosis value of knee MR-arthrography since the recent approval of intra-articular gadolinium use, by this country's healthcare authorities. This study objective is to verify the MR-arthrography superiority on conventional knee MRI, in meniscus and cartilage knee lesions diagnosing accuracy both in regard to sensitivity and specificity. HYPOTHESIS: MR-arthrography, represents in some pathologic situations, a more accurate source of information than conventional MRI. MATERIALS AND METHODS: Over a 27 months period, 25 patients, scheduled to undergo a knee arthroscopy volunteered, after having been fully informed of the possible interest and risk of the MR-arthrography examination, to participate in this study. Twenty-one of them were finally included since in four cases the surgical indication was not confirmed. The group consisted of 15 males and six females with an average age of 35.7 years. All of them consecutively underwent conventional MRI, MR-arthrography finally followed by arthroscopy. The MRI and MR-arthrograms results were compared to the arthroscopy findings using the nonparametric Kappa test. RESULTS: To diagnose meniscal tears, statistical agreement measure for MRI with arthroscopy was good (K=0.69) but not as good as the MR-arthrography/arthroscopy agreement which, by itself was excellent (K=0.84). As a diagnosis tool, the sensitivity and specificity of MR-arthrography (respectively 100 and 89.6%) were much higher than the corresponding values observed in conventional MRI (92.3 and 82.8%, respectively) which nonetheless remain satisfactory. The meniscal tears characterization seemed to be better interpreted using MR-arthrography. As far as the chondral lesions in this series, they were predominantly located on the patellar surface and in the medial femorotibial compartment. For diagnosing the latter, the MRI/arthroscopy agreement was good (K=0.70) but not as good as the MR-arthrography/arthroscopy agreement (K=0.805) which can be rated excellent. The detection sensitivity thus increased by 10% with gadolinium intra-articular injection. However, assessment accuracy of the lesions depth was mediocre, with frequent errors for the intermediary stages. DISCUSSION: Intra-articular gadolinium injection improved MRI performances for numerous reasons: filling the joint, reinforcing the synovial fluid signal, and enhancing anatomic structures contrast on the T1-weighted sequences images. In this study, MR-arthrography appeared to be superior to conventional MRI in meniscal and cartilaginous lesions diagnosis, confirming the results previously obtained in other countries. In light of these results and other data from the literature, MR-arthrography can be indicated as an alternative to CT-arthrography in various clinical situations: detection of recurrent tears on operated menisci, search for cartilaginous lesions or foreign bodies in the joint space, and preoperative assessment before chondral repair procedures. However, conventional MRI remains the reference examination for studying cartilage, because the low resolution of MR-arthrography limits its performances in quantitative assessment of lesions depth.

[First treatment of distal loss of tissue on lower limbs. About 15 cases]. / Stratégie thérapeutique initiale dans les pertes de substance distales du membre inférieur d'origine traumatique. A propos de 15 cas.

Distal extremity of lower limb sustains the complications of loss of tissue: problem of coverage (cutaneous and tendon necrosis, osteoarticular infection. The whole point of the surgery is to fight against the infection by repeated debridments, against the deformations or their correction by early osteosynthesis (pins and external fixation). The coverage is very important in this treatment: either with Vacuum-Assisted Closure (VAC) and skin graft or fasciocutaneous flap. In spite of this management, the after-effects are important although the conservative treatment is the determining factor of satisfaction.

[Intracardial migration of a bullet: diagnosis and management]. / Migration intracardiaque d'un projectile d'arme à feu: diagnostic et prise en charge.

Venous pellet embolism to the cardia after shotgun wound is a very rare occurrence. Number and size of pellets, at the impact make this migration easier; embolism is asymptomatic and may occur 15 years after the injury. Many problems must be mentioned: mechanics of entry into the heart (own velocity, venous flow), topographic diagnosis (chest X-ray, transthoracic, transoesophageal ultrasound and CT-scan), local outcomes of this projectile (local erosion, clot, endocarditis), destination of a new migration (pulmonary embolism, left heart), indications of extraction, supervision. Extraction musn't be systematic, but only in the event of a patent foramen ovale with a risk of systemic embolism, which clinical outcomes are most serious or in the event of complications. The authors report on a 22 years old patient observation whose treatment was abstention and supervision.