Changes in plantar pressure distribution after Achilles tendon augmentation with flexor hallucis longus transfer.

BACKGROUND: Augmentation of the Achilles tendon with flexor hallucis longus is an established method to treat neglected ruptures and severe cases of chronic tendinopathy. After transfer of the muscle/tendon, good pain reduction and improved plantar flexion have been reported. To date, only one study has investigated the effect of FHL transfer on forefoot biomechanics. Theoretically, there should be a partial transfer of forefoot loading towards the lateral metatarsal heads during push-off, resulting in an asymmetric gait. METHODS: 13 patients were examined clinically and using pedobarography with a mean follow-up of 46 months (minimum 24) after Achilles tendon augmentation with flexor hallucis longus. Parameters of the forefoot were investigated to detect differences in pressure and force distribution, load transfer to other areas of the forefoot, and asymmetries compared to the non-operated leg. The results are discussed with regard to clinical relevance. FINDINGS: Clinically, there were no subjective or objective gait asymmetries. All patients were free of pain and without restrictions during normal walking. In general, pedobarography showed an unloading of the first toe with a load transfer to the metatarsal heads on the operated side. All results featured high inter-subject and within-subject variability. INTERPRETATION: Due to the high within-subject variability, there is inconsistency within the results making interpretation difficult. However, the results confirm the hypothesis that unloading of the first toe during push-off and an asymmetrical loading pattern can be measured after harvesting of the flexor hallucis longus. The clinical situation of the patients did not reflect a visible amount of gait asymmetry. Differences in loading patterns 2 years after flexor hallucis longus transfer for Achilles tendon augmentation appear to be well compensated.

Internal fixation of complex fractures of the proximal humerus.

We treated 34 consecutive articular fractures of the proximal humerus in 33 patients with good bone quality by open reduction and internal fixation. Anatomical or nearly anatomical reduction was achieved in 30, at a mean follow-up of 63 months (25 to 131), complete or partial avascular necrosis had occurred in 12 cases (35%). Two patients subsequently underwent arthroplasty and six further patients required additional surgery. The 32 patients who did not require arthroplasty obtained a mean Constant score of 78 points or 89% of an age- and gender-matched normal score (66 points or 76% in the presence and 83 points or 96% in the absence of avascular necrosis (p < 0.0005)); 22 were painfree, and seven had mild pain and three moderate pain. The mean active anterior elevation was 156 degrees. Internal fixation of complex fractures of the proximal humerus restored good shoulder function if avascular necrosis did not develop.

Cartilage lesions in the ankle joint: comparison of MR arthrography and CT arthrography.

OBJECTIVE: To compare MR arthrography and CT arthrography for the evaluation of cartilage lesions in the ankle joint. DESIGN AND PATIENTS: Thirty-six consecutive patients with clinically suspected cartilage lesions were prospectively included in the study. A 1:1 mixture of diluted gadoteridol (4 mmol/l) and iopamidol (300 mg iodine/ml) was injected. The articular cartilages of the talus, tibia, and fibula were analyzed separately by two musculoskeletal radiologists. A review panel consisting of two musculoskeletal radiologists and an orthopedic surgeon represented the standard of reference. RESULTS: For reader 1 accuracy of MR arthrography in the talus/tibia/fibula (88%/88%/94%) was slightly inferior to CT arthrography (90%/94%/92%). For reader 2, the accuracy was 76%/78%/83% for MR arthrography, and 92%/93%/92% for CT arthrography, respectively. Interobserver agreement for MR arthrography was 79%/74%/89% (kappa 0.47/0.34/0.27), while interobserver agreement for CT arthrography was 89%/90%/89% (kappa 0.69/0.54/0.54). CONCLUSION: CT arthrography appears to be more reliable than MR arthrography for the detection of cartilage lesions in the ankle joint.

Failure of reinserted short external rotator muscles after total hip arthroplasty.

The frequency and point in time of failure of repaired short external rotator muscles were determined in 27 total hip arthroplasties. The piriformis, triceps coxae, and obturator externus muscles were released close to the trochanter and reattached only if tension was low and if the tendon tissue allowed a good hold for anchoring the stitch. A radiopaque marker was attached to each side of the suture with maximum 1-cm distance between opposite markers. The distance between markers was determined on radiographs obtained 1 day and 3 months postoperatively; >/=2.5 cm indicated failure. Of 50 repaired short external rotator muscles, 35 (70%) failed-26 within the first day and 9 within 3 months postoperatively. In 2 hips, no failure of the repaired short external rotator muscles was observed. Repair of the short external rotator muscles after total hip arthroplasty contributes little to prevention of hip dislocation.

[Clinical examination of the shoulder]. / Die klinische Untersuchung der Schulter.

The clinical examination is decisive in the diagnosis of shoulder pathologies. This examination should be exact and systematic and in relation with the anatomical structures. With patient history, the clinical examination allows in over 90% of the cases a correct diagnosis. Complementary exams such as standard X-rays, CT-Scan, MRI and neurological examinations serve to confirm the diagnosis and to allow precise surgical planning.

[Garré sclerosing osteomyelitis]. / Osteomyelitis sclerosans Garré.

Osteomyelitis sclerosans Garré is still not completely understood. In spite of the fact that it is caused by bacterial infection, in most cases no bacterial growth can be discovered in culture. Furthermore, it remains open whether the chronic process is maintained by low-grade persistent infection or is maintained by itself after sterilization of the infection. Newer studies that may prove the presence of bacteria, e.g., by PCR, may elucidate the causes in the future. Sclerosing bone disease, sometimes multifocal, which present the same clinical, radiographic and histological features as chronic sclerosing osteomyelitis may be associated with diseases such as palmoplantar pustulosis, colitis ulcerosa, Crohn's disease, etc. and are reported as SAPHO (synovitis acne pustulosis hyperostosis osteitis) syndrome. In these diseases bacterial growth is almost always negative. However, temporary improvement under antibiotic therapy may be observed. A relationship between typical isolated chronic sclerosing osteomyelitis and SAPHO syndrome may exist, but the diseases should at present be differentiated. Neoplasms such as osteoid osteoma, Ewing sarcoma, or eosinophilic granuloma may simulate primary sclerosing osteomyelitis, and pathological examination of peripherally taken specimens may appear to be compatible with the diagnosis of sclerosing osteomyelitis. It should be appreciated that malignant tumors--even though this is the exception--can present a chronic, mild picture. Treatment of osteomyelitis sclerosans Garré needs be determined on an individual basis. A conservative approach with antibiotics usually leads only to temporary pain relief. The biopsy with opening of the medullary canal is sometimes sufficient for healing, while in extreme situations only segmental or even complete resection of the diseased bone case result in a permanent cure.

Osteomyelitis sclerosans Garré.

Osteomyelitis sclerosans Garré is still not completely understood. In spite of the fact that it is caused by bacterial infection, in most cases no bacterial growth can be discovered in culture. Furthermore, it remains open whether the chronic process is maintained by low-grade persistent infection or is maintained by itself after sterilization of the infection. Newer studies that may prove the presence of bacteria, e. g., by PCR, may elucidate the causes in the future. Sclerosing bone disease, sometimes multifocal, which present the same clinical, radiographic and histological features as chronic sclerosing osteomyelitis may be associated with diseases such as palmoplantar pustulosis, colitis ulcerosa, Crohn's disease, etc. and are reported as SAPHO (synovitis acne pustulosis hyperostosis osteitis) syndrome. In these diseases bacterial growth is almost always negative. However, temporary improvement under antibiotic therapy may be observed. A relationship between typical isolated chronic sclerosing osteomyelitis and SAPHO syndrome may exist, but the diseases should at present be differentiated. Neoplasms such as osteoid osteoma, Ewing sarcoma, or eosinophilic granuloma may simulate primary sclerosing osteomyelitis, and pathological examination of peripherally taken specimens may appear to be compatible with the diagnosis of sclerosing osteomyelitis. It should be appreciated that malignant tumors - even though this is the exception - can present a chronic, mild picture. Treatment of osteomyelitis sclerosans Garré needs be determined on an individual basis. A conservative approach with antibiotics usually leads only to temporary pain relief. The biopsy with opening of the medullary canal is sometimes sufficient for healing, while in extreme situations only segmental or even complete resection of the diseased bone case result in a permanent cure.

[Cornea procurement and grafts and number of patients on waiting lists. Data collection in France between 1990 and 1994]. / Prélèvement et greffes de cornées et nombre de patients en attente de greffe. Recensement en France entre 1990 et 1994.

OBJECTIVES: Analyze annual corneal graft procurement and transplantation in France. METHODS: Data collected from all public and private health centers in France in a survey conducted in August 1994 by the general health directory were analyzed by the French Graft authorities. RESULTS: Between 1990 and the first semester 1994, an annual mean of 3205 corneal grafts were performed in France. The annual number of grafts fell by 27% between 1991 and 1992 then stabilized at 2700 grafts per year. Eighty percent of the grafts were performed in public institutions. Less than 4% of the patients were foreigners. The number of patients on waiting lists on June 30, 1994 was 7129, i.e. 2.7 times the number of transplantations in 1993. Mean annual cornea procurement between 1991 and the first semester 1994 was 2930. Corneas were removed at the morgue in 78% of the cases or in the operating room in 19% (multiple organ procurement) and 1.5% (cornea alone). Grafted corneas came from public hospitals in 72% of the cases. Fifty-seven percent of the grafts used in private institutions were imported. The mean annual number of imported corneas can be estimated at 280. This number has increased by 127% since 1990 and corresponds to 8% of the grafted corneas. CONCLUSION: The number of corneal grafts in France is similar to that in other European countries, but the number of patients on waiting lists is high and French eye banks had a restricted role.

[Human immunodeficiency virus (HIV) infection in mothers and infants in French Guyana. Epidemiologic study apropos of 44 women having conceived 55 children]. / L'infection par le virus de l'immunodéficience humaine (VIH) chez la mère et l'enfant en Guyane Française. Etude épidémiologique à propos de 44 femmes ayant eu 55 enfants.

The French Guyana is an Overseas French Department in South America, with 100,000 inhabitants among them are 20% of Haitian immigrants. At 31 December 1987, 103 AIDS cases have been recorded, 86% by heterosexual transmission. The first case dated May 1979 was retroactively diagnosed in an Haitian parturient, thank to her serum kept in the Pasteur institute of Cayenne. 44 women got their pregnancy during their HIV infection: 5 with clinical and biological evidence of AIDS, 7 developed AIDS after getting pregnant, and 10 out of these 12 women died. All of them were from a rather low social group and, generally, were not married. 43 are black (40 Haitians and 3 Guyanese Creoles), one is Indian and presented some psychic disorders. The mean age was 32 1/2 (from 15 to 51 years old). 55 babies were born: 12 developed AIDS (6 died during the first 15 months of their life); 14 are HIV +, 3 stillborns, 4 never tested and 22 developed negative reaction (with ELISA and Western-Blot) between 7.5 and 10 months of their life. Two Hutchinson's triads were observed. Prurigo is the most commonly skin manifestation observed.