Étude comparative de l’efficacité et de la tolérance de l’étidronate et de l’alendronate au cours de l’ostéoporose postménopausique. Influence de l’adjonction d’un traitement hormonal substitutif

Objectives. To compare the efficacy and safety of etidronate and alendronate in patients with postmenopausal osteoporosis and to assess the efficacy of either bisphosphonate in combination with hormone replacement therapy (HRT). Patients and methods. In this pragmatic study, the main efficacy criterion was the mean annual change in bone mineral density (BMD). Patients who had a past or current history of etidronate or alendronate treatment for postmenopausal osteoporosis with at least 18 months follow-up and an evaluation in 1999 were eligible. Recruitment was in an outpatient clinic with a special focus on metabolic bone diseases. Osteoporosis was defined as at least one low-energy fracture or as a lumbar spine or femoral neck BMD decrease to at least 2.5 SD below the mean in young women. HRT was not an exclusion criterion provided treatment duration was longer than one year. Etidronate was given cyclically (14-day courses in a dosage of 400 mg/d separated by 76-day intervals with calcium and vitamin D supplementation) and alendronate was given daily in a dosage of 10 mg/day. Results. Of the 99 patients who met our inclusion criteria, 53 received etidronate (including 23 on HRT) and 46 alendronate (18 on HRT). Repeat BMD measurements were obtained in 88 patients, including 11 who stopped their bisphosphonate therapy within the first year of use because of adverse events. Lumbar spine BMD (mean ±SD) increased significantly both in the etidronate group (+2.1%±0.7%/year) and in the alendronate group (+5.3%±0.9%/year). The increase was significantly greater with alendronate (P<0.01). The lumbar spine BMD increase was largest in the patients on alendronate and HRT (+6.5%±1.4%/year) and was smallest (and nonsignificant) in the patients on etidronate without HRT (+1.2%±0.8%). Femoral neck BMD showed no significant changes in any group. In the intention-to-treat analysis, fractures occurred in 12 etidronate patients (22.6%) and six (13.0%) alendronate patients (nonsignificant). Adverse events requiring bisphosphonate discontinuation before the scheduled date of the follow-up BMD measurement occurred in one patient (1.9%) in the etidronate group (generalized osteomalacia) and in ten patients (21.7%) in the alendronate group (upper or lower gastrointestinal tract symptoms in six and four patients, respectively; P<0.01). Conclusion. Both etidronate and alendronate significantly increased lumbar BMD, but the effect was significantly more marked with alendronate. Conversely, adverse effects, most notably gastrointestinal symptoms, were more common with alendronate, so that premature treatment discontinuation because of adverse events were more common in the alendronate group. Both differences should be taken into account when selecting the best drug for a patient with postmenopausal osteoporosis.     

L’arthroplastie totale de hanche chez l’enfant et l’adolescent

Arthritis Arthritis of the hip in children and adolescent can induce lesions of the articular cartilage and severe handicap. When conservative surgical methods are without benefit, total hip arthroplasty should be an alternative solution.Indications: Chronic pain, abnormal social life and scolarity, stiffness and impossibility for osteotomies are the main criteria to decide and to choose for an arthroplasty.

Two main groups of etiology are as follow

• * group I concerns rhumatologie arthritis. Arthroplasty is decided with pediatricians, physiotherapists… Other joints are often involved and post-operative cares need intensive physiotherapy.

Femoral head necrosis of renal disease and sickle cell disease belong to this group.* group II concerns sequelae of previous femoral osteotomy: septic osteoarthritis, severe stiffness, sequelae of hip dislocation, necrosis of slipped capital epiphysiolysis…Since 1990, Dr J.L. Jouve has operated on 11 hips in patients aged for 14 to 20. Prosthesis used were custom made, Symbios, Switzerland.Results group I: The custom made in this group is interesting because it is obvious to maintain the largest bony pool and to avoid to ream the metaphysis and diaphysis. It is also necessary to thinck in advance for further procedure because these patients are young. Technical surgical approach is without any particularity, no case of fracture was noticed. Post-operative weight-bearing was delayed for 45 days. With a short follow-up of 2 years, results are excellent.Results group II: The custom made is necessery in these cases with an abnormal morphology of the proximal femur and narrow canal following earlier femoral osteotomies. Immediate results are also excellent.Conclusion: Hip arthroplasty with custom made is a nice procedure when other surgical treatments are not possible. But further studies are necessary with a larger follow-up.

Tumors Osteosarcoma and Ewing’s sarcoma needs sometimes wide resections of the proximal femur and reconstruction of the hip joint. In our experience and ISOLS’ series, it seems that following data are favourable:

• - cemented complete prosthesis of the femur resected and no allograft,
• - excellent reconstruction of the muscles of the hip: extensors, abductors and fascia lata, without to try a fixation of these muscles on the prosthesis
• - use of an acetabular mobile cup to preserve further surgery with, for exemple, an acetabular arthroplasty.

Two cases of Ewing’s sarcoma are presented, girls aged 15 and 12.Length of the resection was 23 and 19 cm. Post-operative results are good.     

L’incidence de l’IRCT en 2011

This chapter provides a set of indicators on incident patients with renal replacement therapy. In 2011, in 25 French regions (99% population), 9 248 patients started a treatment by dialysis (incidence of dialysis: 149 per million inhabitants) and 334 patients with a pre-emptive graft without previous dialysis (incidence of pre-emptive graft: 5 per million inhabitants). One patient among two are over 70 years old at renal replacement therapy initiation. As in 2010, incidence rate seems to stabilize.     

Néphrocalcinose de l’enfant

Nephrocalcinosis is defined by calcium phosphate or calcium oxalate deposits in the kidney parenchyma, particularly in tubular epithelial cells and interstitial tissue. It should be differentiated from urolithiasis where calcium salts deposits are located in the kidney and urinary tract. The epidemiology of nephrocalcinosis in children is unknown but the condition is not so rare, with an increased incidence in preterm infants. Often detected as an incidental finding, nephrocalcinosis may be classified according to the radiological type: medullary, cortical or diffuse. Nephrocalcinosis in children can be caused by a variety of etiology. The most common causes concern medullary nephrocalcinosis and include hereditary tubular disorders, in particular distal renal tubular acidosis and Dent disease, metabolic disorders such as idiopathic hypercalciuria and hyperoxaluria, and iatrogenic causes such as vitamin D intoxication. In the newborn, the main cause is hypercalciuria of the premature baby, whose multifactorial origin is largely iatrogenic. Primary hyperoxaluria which can lead to early onset nephrocalcinosis and usually to chronic kidney disease should always be considered and further investigated. In order to provide a specific diagnosis, it is essential to take into account the family history, the clinical context and complete laboratory data. Early initiation of an appropriate etiological treatment is recommended and may prevent or delay the progression to chronic kidney disease in some cases.