[The rehabilitation of elderly amputees]. / La rééducation des amputés âgés.

Rehabilitation of elderly amputees raises several issues. Taking into account that amputations are frequently performed in elderly patients, with vascular diseases, it seems relevant to ask whether it is preferable to perform an amputation and quickly rehabilitate the patient or to attempt revascularisation and save the patient's limb. The knowledge of the outcome of amputation is crucial for the choice of treatment. Therefore, we discuss limb amputation in old patients in terms of epidemiology, aetiology, functional characteristics, specific problems and results with regards to expectations. Types and characteristics of prostheses, as well as rehabilitation and cost-effectiveness are briefly discussed. It is concluded that amputation is a mutilating procedure which carries for the elderly a poor outcome in terms of rehabilitation. Consequently any surgical procedure that may spare the limb should be preferred.

Longitudinal study of the bone mineral content and of soft tissue composition after spinal cord section.

We present the results of a 1 year longitudinal study of bone mineral measurements and soft tissue composition in supra- and infra-lesional areas of 31 patients with a spinal cord injury (level D2-L3). Like others, we observed a rapid decrease of BMC in the paralysed areas, of approximately 4%/month during the first year in areas rich in trabecular bone and of approximately 2%/month in areas containing mainly compact bone. Lean soft tissue mass (muscle mass) decreases dramatically during the first months post injury in the legs, while fat content tends to increase. Though lean mass is better maintained in patients who develop spasticity, the evolution of BMC does not differ significantly between the groups of flaccid and spastic patients. In patients with partial or complete neurological recovery, a deficit in BMC of approximately 10% with regards to the initial value is still observed at 1 year in the lower limbs. The lean mass of the upper limbs increases early after the cord injury, because of intensive rehabilitation. No significant change in BMC was observed in the supra-lesional areas. These data confirm the rapid loss of bone in the paralysed areas of paraplegic patients, which occurs independently of the presence of spontaneous muscle activity or of passive verticalisation. In patients with recovery, BMC does not return to pre-injury values within 1 year. Thus, there would be an interest in preventing bone loss early in the course of the disease.

[Changes in the motor units in patients with traumatic paraplegia]. / Modifications des unités motrices chez des malades atteints de paraplégie traumatique.

Neuromuscular biopsies were obtained in 10 patients with traumatic spinal cord lesions at various levels and in one patient with cerebral lesions due to a long lasting coma. In all cases, there was a rapid onset of both fibers types atrophy, with numerous transitional type III and intermediate fibers. Only the two patients with cervical lesions had an increased terminal innervation ratio suggesting denervation. Our observations do not support the hypothesis of a transneuronal degeneration. These changes cannot be related to disuse only as the atrophy does not preferentially involve type II fibers. The underlying neural mechanism of spasticity in muscle of patients with cortico-spinal lesions could explain the change of the histochemical pattern of the muscle fibers.