Open elbow arthrolysis for posttraumatic elbow stiffness.

OBJECTIVES: The elbow joint is vulnerable to stiffness, especially after trauma. The aim of this study was to evaluate the results of open arthrolysis for posttraumatic elbow stiffness. DESIGN: Cohort retrospective study. PATIENTS: Eighteen consecutive patients were evaluated by an independent observer at an average of 16 months (6 to 43) after open elbow arthrolysis was performed for posttraumatic stiffness. Initial traumas were: isolated fractures (11) or dislocation (1) and complex fracture-dislocations (6). Initial treatments were: nonoperative (3), radial head resection (1), and ORIF (14). Patients presented predominantly with mixed contractures (combined extrinsic and intrinsic contractures). INTERVENTION: Open elbow arthrolysis. MAIN OUTCOME MEASUREMENTS: Elbow function and patient satisfaction were the principal outcome measures. At follow-up European Society for Shoulder and Elbow Surgery (SECEC) elbow scores were calculated. RESULTS AND CONCLUSIONS: Three patients had minor postoperative complications: 1 partial wound dehiscence, 1 subcutaneous infection, and one seroma. None of these complications influenced the final result clinically. The mean total increase in range of motion was 40 degrees (13 to 112 degrees), with a mean gain in flexion of 14 degrees (0 to 45 degrees) and 26 degrees in extension (5 to 67 degrees). No patient showed signs of elbow instability. There was no radiographic evidence of osteoarthritis progression at follow-up. We did not find any correlations between the type of stiffness, the approaches used, and the results. However, patients with the greatest preoperative stiffness had significantly better improvement of mobility (P<0.001). The best results were obtained in patients who had arthrolysis done within 1 year after the initial trauma (P=0.008). The mean SECEC scores were 88 (52 to 100) for the injured elbows, and 96 (88 to 100) for the contralateral elbows. CONCLUSION: Open elbow arthrolysis for patients with posttraumatic stiffness improves joint function and provides patient satisfaction. The best results, in terms of gain of motion and patient satisfaction, were obtained in patients with severe stiffness who had operations within the first year after initial trauma.

High prevalence of osteoporosis in Swiss women aged 60 and older: a 2-year pilot screening campaign.

Background: Osteoporosis (OP) is frequent in postmenopausal women, but remains underdiagnosed and undertreated. In Switzerland, DXA is not reimbursed by the insurances for screening, even if it is recommended to test women's Bone Mineral Density (BMD) at the age of 65. Methods: To assess the feasibility of a screening program for OP, the Bone diseases center of Lausanne has been mandated to perform a 2-year information and screening campaign (3 days per months) for women age 60 and older through the state of Vaud using a mobile unit for bone assessment. This project is still ongoing. Women are informed by media for dates and screening locations. Appointments are taken by phone. Women known for osteoporosis or already treated are excluded. During the evaluation every women is assessed by a questionnaire for risk factors, by a DXA measurement (Discovery C, Hololgic), and by Vertebral Fracture Assessment (VFA) for Genant's grades 2 and 3 prevalent vertebral fractures (VF). Women are considered at high risk of fracture if they have a hip fracture, a VF, another fragility fracture with a BMD T-score ≤-2 or a BMD T-score ≤-2.5. Results: After 17 months (50 days of screening), 752 women were assessed, mean age 66±6 yrs, mean BMI 26±5 kg/m2, mean lowest T-score -1.6±1.0 SD. 215 women (29%) were considered at high risk, 92 of them (12%) having established OP and 50 (7%) having one or more fragility VF. VF were unknown for 83% of the women and discovered by VFA. The number needed to screen (NNS) were 3.5 for high risk women, 8.2 for established OP and 15 for VF. Conclusions: After near ¾ of the project, prevalence of women at high risk of fracture was high, with a NNS below 4. Knowing the global cost of OP and that current treatment have a high efficacy for fracture risk reduction, such a screening program could have a positive economic impact. VFA allowed discovering many women with unknown VF, who were at very high risk of further fractures. A systematic screening for VF should be added to BMD measurements after the age of 60.

Evolución tectonoestratigráfica de los Catalánides

Proposem una divisió dels Catalanids en unitats que reflecteixen un comportament paleogeografic i estratigrafic diferent durant l'etapa preorogenica (Mesozoic) i un de tectonic relativament diferenciat durant l'etapa compressiva (Paleoge). Distingim els sectors (extern, intermedi i intern) limitats per falles de sbcol longitudinals, paral.leles a la serralada, la majoria de les quals es concentra en una zona que separa els sectors extern i intern. En aquesta zona (sector intermedi) s'hi atasconen les unitats litoestratigrafiques mesozoiques. Aquest atasconament, conjuntament amb la reactivació de les fractures profundes, és el responsable, durant l'etapa compressiva, de la localització en el sector intermedi dels fronts de les principals estructures d'encavalcament. També distingim les unitats que hem anomenat domini; (septentrional, central i meridional), que estan limitades per fractures transversals a la serralada. Així, doncs, les unitats queden limitades per dos sistemes de fractures de sòcol aproximadament ortogonals.

Les traitements de l'ostéoporose (à l'exception de la substitution hormonale et de ses dérivés) [Treatment of osteoporosis (with the exception of hormone replacement and its derivates]

Calcium and vitamin D supplementation are warranted for the treatment of osteoporosis, when other specific drugs are used. Vitamin D supplementation is necessary when the plasma level of 25-hydroxy-vitamin D is below 30 nmol/l (12 pg/l) in order to avoid any increase of the plasma parathyroid hormone level. Bisphosphonates are the most widely drugs used. Recent advances will provide patients with a more convenient therapeutically equivalent alternative: the once-weekly oral dosing regimen and probably the possibility to give infusions at intervals of up to one year. Parathyroid hormone administered subcutaneously daily produced a dramatic increase of trabecular and cortical bone mineral density, and an important decrease of vertebral and nonvertebral fracture risk. Strontium is a new original drug, which stimulates bone formation, and inhibits bone resorption. It significantly improves trabecular and cortical bone mass. Calcitonin not only prevents the recurrence of vertebral fractures, but possibly could decrease hip fractures risk. Hydrochlorothiazide preserves the bone mineral density, and decreases nonvertebral fracture risk, as showed in epidemiological studies. Large clinical trials with statins therapy in appropriate populations are required to find out whether these drugs have any role in preventing fractures.

Acquisitions de la littérature en médecine interne générale ambulatoire en 2010 [2010 findings from literature on general internal ambulatory medicine].

From our reading over the current year 2010 we have singled out 8 items which seem to us significant for the practice of medicine. Small doses of colchicine are useful in the treatment of gout. No efficacious treatment for muscular cramps can be recommended. A cervical collar can be usefully prescribed for the treatment of cervical radiculopathy. A single dose of azithromycin can be envisaged as a third line treatment of syphilis. High doses of vitamin D should not be prescribed for the prevention of fractures in elderly women because of the risks of falling. The wearing of bifocals can be associated with these risks. A clinical score is available to help with the diagnosis of thoracic pain. The NT-pro BNP is of limited use for the follow-up of patients suffering from heart failure.

Traumatismes du bassin [Pelvic trauma]

Les fractures du bassin, groupe polymorphe, sont liées au mécanisme traumatique. L'enjeu des fractures isolées du cotyle est principalement fonctionnel. Les radiographies standards, les scanner 3D et la classification de Letournel orientent le traitement. Ce dernier visera à rétablir une congruence articulaire prévenant la coxarthrose précoce. Les fractures du pelvis surviennent le plus souvent suite à des traumatismes violents, associés à des lésions viscérales, menaçant le pronostic vital. Le bilan radiologique s'intègre dans une prise en charge pluridisciplinaire grâce au scanner. La classification de Tile/AO permet la description des mécanismes et des lésions et une prise en charge adaptée. En cas de chocs hémodynamiques, la stabilisation externe, suivie si nécessaire de l'embolisation, à une place prépondérante. Pelvic trauma A great variety of very polymorphous lesions of pelvic trauma are deffering from each other by their context, their anatomical aspect and therapeutic implication. In the isolated acetabular fractures, function is mainly at stake. The management consists mainly of re-establishing a joint congruence to prevent early coxarthrosis. Pelvic fractures often occur in violent trauma and are associated with visceral lesions, putting vital prognosis at stake. In case of hemodynamic shock, external fracture stabilization when it is indicated associated to embolisation of pelvic bleeding if necessary and after external fixation are preponderant.

Transolecranon anterior fracture dislocation.

Between January 1996 and July 2003, 93 consecutive patients operated on with a diagnosis of olecranon fractures were identified from our trauma unit files. Fourteen transolecranon fracture-dislocations were found after a retrospective X-radiographic evaluation. Eight patients were women and six were men, with a mean age of 54 years. There were 4 noncomminuted olecranon fractures, treated with K-wires and single tension-band wiring. The remaining 10 fractures were complex fractures, treated in 3 cases with multiple K-wires and single tension-band wiring, in 2 by use of one-third tubular plates, in 1 with a 3.5-mm dynamic compression plate, and in the remaining 4 with 3.5-mm reconstruction plates. Ligament repair was not performed in any case. Three patients needed reoperation because of early failure of primary fixation. Patients were reviewed at a mean follow-up of 3.6 years. Two reported difficulties in daily activities, none with any symptoms of elbow instability. According to the Broberg and Morrey score, 4 patients had excellent results, 6 had good results, 2 had fair results, and 2 had poor results. Four patients showed signs of degenerative arthritis on the radiographs obtained at follow-up. We conclude that transolecranon fracture-dislocation is an underreported and misdiagnosed injury. Various fixation techniques can restore the anatomic relationships and contour of the trochlear notch; the imperative goal is to obtain a good stable primary fixation and allow early active mobilization.

Prescription footwear for severe injuries of foot and ankle: effect on regularity and symmetry of the gait assessed by trunk accelerometry.

After foot and/or ankle fracture, the restoration of optimal gait symmetry is one of the criteria of recovery. Orthotic insoles and orthopaedic shoes improve gait symmetry and regularity by controlling joint motion and improving alignment. The aim of the present study was to assess the effect of prescription footwear on gait quality by using accelerometers attached to the lower back. Sixteen adult patients with persistent disability after ankle and/or foot fractures performed two 30-s walking trials with and without prescription footwear (insoles and stabilizing shoes). Sixteen control subjects were also tested for comparison. The autocorrelation function was computed from the acceleration signal and the first two dominant periods were assessed (d1 and d2). Two parameters were used: (1) Stride Regularity (SR) which expresses the similarity between strides over time (d2), and (2) Stride Symmetry (SS) a ratio (d1/d2) which expresses the left/right similarity of gait independently of repeatability in the successive movements of each limb. In control subjects, SR and SS were 0.86+/-0.05 (correlation coefficient) and 81+/-10%, respectively. In the patient group, the effect of footwear was significant (SR: 0.88+/-0.06 vs. 0.90+/-0.05, SS: 38+/-23% vs. 46+/-27%). Pain was also significantly reduced (-34%). By using a rapid and low-cost method, we objectively quantified gait quality improvement after footwear intervention, concomitant to pain reduction. Substantial inter-patient variability in the footwear outcome was observed. In conclusion, we believe that trunk accelerometry can be a useful tool in the field of gait rehabilitation.

Dissolution-reprecipitation of zircon at low-temperature, high-pressure conditions (Lanzo Massif, Italy)

An eclogite facies meta-plagiogranite from the Lanzo massif (western Alps, Italy) contains crystals of zircon intimately associated with allanite. Zircon displays different microtextures ranging from pristine, euhedral, and magmatic to fractured, porous varieties with mosaic zoning, and pervasive recrystallization into euhedral microcrystals. Fractures and voids in the recrystallized zircon microcrystals are mainly filled by high-pressure Na-rich pyroxene. Electron backscattered diffraction analysis revealed a similar crystallographic orientation for primary magmatic zircon crystals and microcrystals, with less than 2 degrees misorientation among neighboring microdomains. The textural change is coupled with chemical and isotopic modifications: recrystallized zircon domains contain significantly less Th and light- to mid-REE, but are richer in Sr than magmatic zircon crystals. Magmatic zircon preserves the protolith U-Pb age of 163.5 +/- 1.7 Ma, whereas zircon microcrystals have a mean age of 55 +/- 1 Ma. The coexisting allanite also contains inclusions of Na-rich pyroxene and has chemical features (elevated Sr and Ni contents and lack of Eu anomaly) indicating formation at high pressure. Despite being associated texturally with zircon, allanite yields a younger Th-Pb age of 46.5 +/- 3.0 Ma, suggesting that the Lanzo unit remained at relatively high pressure conditions for similar to 8 m.y. Zircon recrystallization proceeded with volume reduction and loss of material to an alkaline metamorphic fluid that acted as the agent for a coupled dissolution-reprecipitation process. Recrystallization occurred with minimum transport, in a low-strain environment, and was not significantly enhanced by metamictization. The source of the fluid for zircon recrystallization is most probably related to prograde devolatilization reactions in the surrounding serpentinite.

Epiphysenfugenverletzungen der distalen Tibia. Sinnvolle Mehrinformation durch die MRT? [Epiphyseal injuries of the distal tibia. Does MRI provide useful additional information?]

Plain film radiography often underestimates the extent of injury in children with epiphyseal fracture. Especially Salter-Harris V fractures (crush fracture of the epiphyseal plate) are often primarily not detected. MRI of the ankle was performed in 10 children aged 9-17 (mean 14) years with suspected epiphyseal injury using 1.0-T Magnetom Expert. The fractures were classified according to the Salter-Harris-Rang-Odgen classification and compared with the results of plain radiography. In one case MRI could exclude epiphyseal injury; in four cases the MRI findings changed the therapeutic management. The visualisation of the fracture in three orthogonal planes and the possibility of detection of cartilage and ligamentous injury in MR imaging makes this method superior to conventional radiography and CT. With respect to radiation exposure MRI instead of CT should be used for the diagnosis of epiphyseal injuries in children.