Diagnostic et traitement de la rupture du tendon d'Achille [Diagnosis and treatment of the ruptured Achilles tendon].

The treatment of the recently ruptured Achilles tendon can be conservative or surgical. The conservative treatment may be carried out using either a static cast immobilisation or using a dynamic brace and an early functional rehabilitation. The surgical technique can be either open or mini-invasive. Neglected and ancient ruptures may need to be treated surgically by a tendinoplasty. There is an ongoing discussion about how to manage the recently ruptured Achilles tendon, especially since recent descriptions of conservative-functional treatment procedures and mini-invasive surgical techniques. We present the choice of the different treatment options and the clinical reasoning to identify the best adapted treatment for the individual patient. The ideal treatment option depends on the functional demand and the medical condition of the patient.

Imagerie de la valve aortique en IRM.

Messages à retenir: Les séquences de ciné MR sont utiles pour rechercher une bicuspidie. Les séquences en contraste de phase permettent de mesurer les vitesses et flux transvalvulaires. La fraction de régurgitation est corrélée à la sévérité de l'insuffisance aortique. Une planimétrie peut être effectuée sur les séquences de ciné MR ou de flux. Résumé: L'étude de la valve aortique en IRM nécessite un placement rigoureux des plans de coupes à partir de 2 incidences orthogonales passant par la chambre de chasse. Les séquences de ciné IRM permettent une analyse dynamique de l'ouverture de la valve et sont utiles pour rechercher une bicuspidie et une dilatation de l'aorte. Leur sensibilité au flux turbulents est relativement faible vu leur TE court, à l'inverse des séquences en écho de gradient à TE long. Les séquences de ciné MR permettent également de calculer les volumes ventriculaires gauches et la fraction d'éjection, paramètres importants dans le traitement. Les séquences en contraste permettent de mesurer la vitesse trans-valvulaire et de calculer le volume éjecté dans l'aorte et le volume régurgité dans le ventricule gauche. Elles peuvent être réalisées dans le plan du flux ou au travers du plan. Il est important de régler correctement la vitesse de codage maximale afin d'éviter des erreurs de codage de vitesse (phénomène d'"aliasing"). Dans le cadre d'une insuffisance aortique, le ratio volume régurgité / volume éjecté, appelé fraction de régurgitation, est relié à la sévérité de la valvulopathie. L'IRM peut également permettre de réaliser une planimétrie de l'orifice valvulaire aortique.

Pulmonary artery rupture during Swan-Ganz catheterisation: a case report

Catheter-induced pulmonary artery rupture is an infrequent complication that may occur during invasive cardiopulmonary monitoring. Fatal cases are uncommon and result from hemoptysis and flooding of the opposite lung with resulting hypoyxia. Alpha-1-antitrypsin deficiency is a rare genetic disorder characterised by low serum levels of alpha-1-antitrypsin, critical in maintaining connective tissue integrity. Besides pulmonary emphysema, recent observations suggest that alpha-1-antitrypsin deficiency may also be involved in vascular wall weakening, thereby predisposing arteries to dissection and aneurysm formation. In this article, we describe an autopsy case of pulmonary artery iatrogenic rupture due to insertion of a Swan-Ganz catheter in an 82-year-old woman suffering from pulmonary hypertension and alpha-1-antitrypsin deficiency. The exact source of bleeding could not be precisely identified during autopsy due to the extent of tissue hemorrhage, though postmortem angiography revealed a contrast medium extravasation from a branch of the left pulmonary lower lobar artery. The case herein emphasises the importance of postmortem angiography in facilitating the detection of vascular injuries, the importance of familiarity with intensive care techniques and procedures on behalf of forensic pathologists as well as in-depth knowledge of all possible contributing conditions and predisposing disorders in the pathogenesis of death.

Lésions endothéliales des ballons de contre-pulsion intra-aortique [Endothelial lesions caused by intra-aortic counterpulsation balloons]

Intra-aortic balloon pump (IABP) is the most frequently used mechanical circulatory support. Repeated trauma on the aortic wall has been reported as a cause of balloon perforation by endothelial denudation of atheromatous plaque. This study analyses the effect of IABP on the endothelium of the calf aorta. In 12 calves (mean weight: 72 +/- 6 kg) an IABP was inserted by femoral route and left during 6 hours on internal mode with a frequency of 80 cycles/min. The animals were sacrificed after the procedure (n = 4), at postoperative day (POD) 7 (n = 4), and at POD 14 (n = 4). In the aorta facing the balloon, nine transmural samples were taken proximally (n = 3), at mid height (n = 3) and distally (n = 3), for histological analysis of the percentage of aortic surface covered with endothelium. The percentage of aortic surface covered with endothelium at POD 0, 7 and 14 was proximally: 72.5 +/- 27.5%, 83.7 +/- 16.9% and 93.3 +/- 8.9% respectively; at mid-height: 50.8 +/- 30.7%, 65 +/- 25% and 95 +/- 5%; and distally: 31.4 +/- 20.1%, 48.3 +/- 34.4% and 85 +/- 10%. A large portion of the aortic endothelium is abraded after 6 hours of IAB pumping. This effect is more important at the distal level of the aorta. After two weeks, most of the endothelium has regenerated.

Traumatic rupture of both peroneal longus and brevis tendons.

Injuries of peroneal tendons are rare. Diagnosis of traumatic rupture is often late and presents as chronic ankle instability. A case of a complete traumatic rupture of both peroneal longus and brevis tendons with acute clinical and radiological diagnosis is presented. Surgical repair was performed by direct end-to-end suture on the 4th day after trauma, with excellent functional outcome at 1-year follow-up.

Rupture of a concealed aneurysm after intravenous thrombolysis of a thrombus in the parent middle cerebral artery.

BACKGROUND: Management of ischemic stroke in the presence of aneurysmal brain disease is controversial. Recent retrospective evidence suggests that in selected patients, intravenous thrombolysis (IVT) remains a safe approach for reperfusion. METHODS: We document a case of post-thrombolysis aneurysmal rupture. Supported by additional scientific literature we postulate that acute aneurysmal thrombosis leading to stroke in the culprit artery may be an ominous sign of rupture and should be considered separately from fortuitously discovered distant aneurysmal disease. RESULTS: A 71-year-old female presented with an acute right middle cerebral artery stroke syndrome. IVT allowed vessel reperfusion and revealed a previously concealed, juxtaposed non-giant M1 segment saccular aneurysm. Secondary aneurysmal rupture ensued. The aneurysm was secured by surgical clipping. Postoperative course was uneventful. CONCLUSIONS: This case shows that despite reports of thrombolysis safety in the presence of brain aneurysms, thrombolysis remains potentially hazardous and hints toward an increased risk when the stroke arises on the parent vessel itself.

Successful embolization of a delayed splenic rupture following trauma in a child.

Delayed rupture of the spleen following trauma is an exceedingly rare phenomenon in children. In the case we have experienced, arterial embolization was successfully performed, surgery was avoided, and functional splenic tissue was preserved. Embolization is of value in the management of blunt splenic injuries in hemodynamically stable children, even after delayed rupture. The exact criteria for its use remain to be established.

Quand faut-il opérer une rupture de la coiffe des rotateurs [When to operate a rotator cuff tear?]

Rotator cuff disease is the most common pathology causing shoulder pain with an overall prevalence rate of 30%. There is a significant association between increasing age and the presence of rotator cuff tears. Spontaneous healing of clinically relevant tears has not been observed. Although satisfactory pain relief is possible without rotator cuff tendon healing, functional outcome is better for healed repairs. Operative treatment must be considered in the context of the reasonable expectations for success. Repairability and potential of surgically tendon construct to heal are important considerations in surgical indications. There is no difference of outcomes between the arthroscopic and the open techniques.

Rupture d'une hyperplasie nodulaire focale. A propos de deux cas [Rupture of hepatic focal nodular hyperplasia. About two cases]

The diagnostics of focal nodular hyperplasia is reached through the use of imaging. When the diagnostic is certain, surgical abstention is the rule. Nevertheless, we were confronted with two cases of a rare complication; that of intraperitoneal rupture. In this situation, we suggest to first do an arteriography to control the bleeding, then to perform surgery when the patient has reached hemodynamic stability. Spontaneous rupture as a complication of benign nodular hyperplasia remains a rare event and only five cases were reported in litterature.