Avulsion de la tubérosité ischiatique chez l’adolescent : à propos de deux cas cliniques

Ischial avulsion, often diagnosed as a musculotendinous injury, is a traumatic pathology related to physical activity. Treatment of ischial avulsion fractures is not consensual. The authors present two case reports of adolescent football players with an ischial tuberosity avulsion submitted to a conservative rehabilitation programme, with different outcomes. One of the patients returned to competition but the other gave up football due to pain. In these case reports diagnosis, treatment and follow-up results are discussed.     

Apport de l’exercice physique et du régime dans la prise en charge de la gonarthrose chez l’obèse

Objective

Our objective was to determine whether exercise and weight loss are more effective either separately or in combination, in improving pain and physical function in obese adults with moderate knee osteoarthritis (OA).

Patients and methods

Forty-five obese adults, with a body mass index greater than 35 kg/m² or 30 ≤ BMI < 35 associated to at least one cardiovascular risk factor, suffering from knee pain with evident radiographic signs of knee OA, were involved in our study. All patients were evaluated at baseline and at the end of the study. The assessment parameters were weight loss, the bioelectric impedance analysis, pain, six-minute walk distance, cardiovascular parameters, and muscular strength. The physical function was measured with the Womac and the Lequesne indexes. Patients were randomized into four groups, a control group (G1), exercise only group (G2), diet plus exercise group (G3) and diet only group (G4).

Results

There was no difference between the four groups at baseline. Significant improvement of function (Womac) was noticed in groups performing exercise only (G2) (26 %), diet plus exercise (G3) (37,89 %) and diet only (G4) (18,34 %). We also noticed an improvement in pain in G2 (p = 0.04), G3 (p < 0.001) and G4 (p = 0.02). The improvement of quadriceps strength was noted only in G2 (p = 0.01) et G3 (p = 0.001) without any change in control group and diet only group (G4). The improvement of cardiovascular parameters was observed only in G2 and G3. Weight loss, decreased BMI and waist circumference was more important in diet plus exercise group (G3).

Conclusion

The combination of weight loss and exercise provide better improvements in physical function and pain in obese adults with knee OA compared with either intervention alone. Exercise used alone or associated to dietary provides better improvements in physical capacity and muscle strength.     

Fracture-avulsion de l’épine iliaque antéro-inférieure et du petit trochanter chez un jeune adolescent

The avulsion fractures of the anterior-inferior iliac spine and lesser trochanter are rare. They occur most often in adolescents during sports activities. The forms in adults are rare. We report a case in a young 15-year-old teenager. He had consulted for pelvic trauma with groin pain and functional impotence of the right lower limb occurred during a recent game in triple jump. Physical examination revealed pain in the mobilization of the right hip in extension. Standard radiography of the pelvis has highlighted an avulsion fracture of the anterior-inferior iliac spine avulsion of the right with small trochanter, which has been confirmed by computed tomography. The patient has been treated orthopedically by rest and landfilling lower limb trauma, evolution was marked the disappearance of pain a few weeks later and resumption of the sporting activity in order to 6 months.     

Prise en charge thérapeutique des pubalgies de l’adulte sportif

Groin pain is a very complex pathology in sports. We described our experience in therapeutic management of male athletes in each specific clinical form of groin pain and for each step of treatment and rehabilitation.     

L’ostéochondrite disséquante du genou chez l’enfant et l’adolescent. Notre expérience à propos de 32 cas

Osteochondritis dissecans (OCD) rarely involves the femoral condyle and affects especially the athletes. Etiology of OCD remains enigmatic. This retrospective study analyzed 32 cases (28 children) stemming from a paediatric series. All the concerned children exercised a sports activity. OCD can be grave on the functional plan and burden the sports future of the child. The clinical symptomatology was poor. The circumstances of discovery were essentially represented by an atypical pain of the knee. The diagnosis was confirmed by a standard radiography revealing a specific hurt of variable aspect, being able to go of a simple suspect line to a big loss of substance at the level of the femoral condyles. The used classifications were the ones of Bedouelle, Cahill, as well as Harding one. Mostly, the pathology was diagnosed at a premature stage I and II of Bedouelle. The examinations of imaging (Magnetic Resonance Imaging [MRI], CT scan) were individually decided to explore the lesion or for a choice of the therapeutics. The stake in simple discharge with a strict stop of the sport gave satisfactory results so clinical as radiological in our study. The surgery was exceptional. The forecast is usually good at the child's subject to an adapted coverage by not allowing passing the hour of the surgery. The sport practised in an excessive, intense way (competitive sport) is recognized as a major risk factor.     

L’apport du muscle pectoralis minor dans le traitement de l’instabilité antérieure de l’épaule

The surgical stabilization of the shoulder knew many technical improvements energy. We propose a preliminary study about an engineering change by the addition of a fourth muscular bolt for the treatment of former instabilities of the shoulder. Our study is prospective gathering 16 patients having a stabilization of the shoulder by a quadruple locking using an osseous thrust by the coaracoid process, a tendineux bolt by a hammock applied thanks to the coaraco-biceps tendon to the lower bank of the sub-scapularis, a capsular bolt by joining the acromio-coracoid ligament to the glenohumeral capsule and a fourth bolt by the joining of the pectoral small tendon to the coraco-biceps. Our results evaluated by the score of Dupaly after 18 months show that the average retreat are satisfactory with an early resumption of the activity (2 months on average). The techniques of former stabilization of the shoulder are currently allowing that triple locking is indicated among all patients whose score ISIS exceeds five points. The addition of small pectoral as fourth bolt seems to us as well interesting because of the good preliminary results.     

La prise en charge rééducative globale de patients présentant un syndrome fémoro-patellaire : la lutte contre l’effondrement du membre inférieur par le renforcement du moyen fessier

The patellofemoral pain syndrome (PPS) is characterized by anterior knee pain and poor patellar kinetics. In this review, we focus on primary PPS. Several local factors are known to provoke knee pain (subchondral bony disorders, retraction of the lateral retinaculum, inflammation of the infrapatellar adipose pad). Furthermore, proximal factors involving the hip and pelvis as well as distal factors involving the ankle and foot explain the impact on lower limb mechanics, for instance on single-stance squat. In the 1980s, the gold standard management strategy for PPS was to strengthen the vastus medialis in order to counter lateral subluxation of the patella during knee flexion. More recently, with improved techniques for neuromuscular biomechanical investigations, several publications propose reinforcing the hip abductor muscles for PPS. This offers a more global approach by correcting the posture of the entire lower limb to provide relief from this difficult-to-treat complex syndrome. Strengthening the hip abductors (gluteus medius) appears to be the best way to eliminate the single-stance lower limb postural failure leading to several musculoskeletal disorders. This new approach to rehabilitation is a validated evidence-based therapeutic strategy.     

L’acide hyaluronique avant l’arthrose : à propos de 339 sportifs

Introduction

Physical activities, through traumas and intensity of practice expose the athletes to cartilage pain caused earlier compared to a population of sedentary people. Lesions at the origin of the pain may be traumatic or microtrauma however without meeting the radio-clinical osteoarthritis criteria defined by the American College of Rheumatology. Hyaluronic acid (HA) is commonly used in the treatment of knee osteoarthritis. It became legitimate to think that the mechanism of action of the product can lead to a pain relief of patients when used in other joints and pre-arthritic stage. As such, we use it in these indications for over 10 years. The objective of this study is to evaluate its effectiveness in the knee, hip and ankle and to identify prognostic factors.

Method

Retrospective study analysing the effectiveness of the viscosupplementation through a questionnaire assessing pain, athletic/professional level, pain relief on a daily basis and satisfaction. All of the lesions have been classified Kellgren 0 and staging of the ICRS for the knee. Definition of the criteria for response on the sedation of pain, and the maintenance of the sport/professional level. We also searched factors prognostications for the knee, only joint with sufficient sample size expected (biometric data: sex, age, body mass index, sports and professional profile, used presentation and prior injected corticosteroid solution).

Results

Three hundred and thirty-nine protocols have been realized to 332 cartilaginous traumatic or microtraumatic degenerative lesions (279 knees with single cartilaginous injury, 61 patients with associated treated meniscal tear, 29 hips, 31 ankles) and seven painful after-effects of osteochondritis. The average age of patients was 39.30 (± 14.38), 76% male; 83.2% had a sports profile with strong joint solicitation. Overall effectiveness was 49.85% (single chondral injury: 46.26%, chondral injury plus meniscal tear both treated: 60.66%, 44.82% for hip and 57.14% for the ankle). Four patients on seven treated for painful sequela of osteochondritis have been relieved. The rate of adverse events was 4.13%, represented by puncture pain or swelling reaction. In the knee, the stage lesion did not impact on efficiency (P = 0.17), neither the presence of an associated meniscal tear non-treated (P = 0.15); the pursuit of a support activity is correlated with a loss of efficiency (P = 0.039).

Discussion

This study is interesting as far as no study in vivo exists regarding the use of HA in support of isolated microtraumatic or traumatic chondral lesions except in the course of surgery of the meniscus with visualization of an arthroscopic cartilage injury. Efficiency appears interesting, almost equal to that found in the available studies on arthritis in these joints, although, because of the heterogeneity of the protocols and the results obtained, the estimation of a reliable response rate seems delicate.

Conclusion

The use of HA for the treatment of the pain of single traumatic or microtraumatic cartilage injury appears safe, with an interesting efficiency to be confirmed by studies of high level of evidence.     

Revue de la littérature des différentes techniques de réduction de la luxation glénohumérale antéro-interne,employées de l’Antiquité à nos jours

The glenohumeral joint is the most mobile articulation of the human body. Its anatomy makes it particularly vulnerable. Anteromedial dislocation is a very common traumatic event. Since antiquity, many methods for reduction have been described, all are far from obsolete. Many can still be used today. Is there an ideal method?     

Ostéochondrites disséquantes rares du genou chez l’enfant. À propos d’un cas tibial et d’ un cas rotulien et revue de la littérature

Osteochondritis dissecans is a rare condition and often involves the medial femoral condyle. We are here reporting two uncommon localizations in children involving the lateral portion of the tibial plateau in one and the patella in the other. They were two fourteen-year-old boys with respectively 4 and 3 months history of a right knee pain and locking. No previous trauma had been noted. X-ray studies and MR images provided definitive diagnosis. However, in the tibial localization, osteochondritis was associated to a damaged lateral discoid menisci and in the patellar localization, the osteochondral fragment was detached in the joint. Regularization of the lateral menisci and removal of a loose body were respectively performed under arthroscopy in the two knees. Literature is reviewed with an emphasis particularly on pathogenesis of these rare localizations.     

L’embrochage en palmier de Kapandji dans le traitement des fractures de l’extrémité proximale de l’humérus

Over a 7-year period (January 2003–December 2009), 18 patients have been treated for proximal humeral fractures after sport injuries using Kapandji's method of internal fixation. Neer classification was used to classify the fractures. Various indications were found, with a majority of two and three part fractures. Complications were not rare, but the functional results following Constant score are very good.     

Force isocinétique des muscles rotateurs de l’épaule dans l’instabilité chronique antérieure

Given the role of dynamic stabilization means in shoulder recurrent anterior instability, due to the failure of passive stabilization means, a better understanding of the role of internal (IR) and external (ER) rotators muscle strength, and their agonist/antagonist balance, could be of interest in the therapeutic arsenal around this disease. In the light of the literature, a deficit of IR and ER muscle strength seems associated with unoperated recurrent anterior instability. After surgical stabilization using the Bristow-Latarjet procedure, there appears a transitional post-surgical deficit of the IR and ER muscle strength compared to preoperative values during 3 to 6 months post-surgery, but the preoperative deficit compared to contralateral shoulder seems to persist despite the surgical procedure and the postoperative rehabilitation care. Evaluation of IR and ER isokinetic muscle strength is relevant in monitoring patients with shoulder recurrent anterior instability, unoperated and post-surgery, in order to determine the orientation of rehabilitation, to help the decision for continuing or not strength rehabilitation, and to help the decision when deciding upon an appropriate time for return to sports.     

Rupture du LCA : cas de l’athlète féminine

Female athletes have 2–3 times more risks of ACL injury than male. Hormonal, anatomical and neuromuscular factors would explain this female predisposition. Prevention training, aimed to avoid “dynamic” valgus, leads to a reduction of ACL injury risks. These programs, including a neuromuscular training, improve knee dynamic control in female athletes and decrease the loadings on the ACL. The aim of this review is to make an inventory of the knowledge on this subject by analyzing theses predispositions and most specially the influence of the neuromuscular factors. Therefore, the purpose is to make a comparative assessment of the various prevention programs to determine the essential elements for an effective intervention of the physiotherapist.     

Lombalgie chronique et réentraînement à l’effort : application de la notion de niveau de douleur cliniquement acceptable

Objectives

To search for predictors of reduced low back pain under the patient acceptable symptom state (PASS) at the end of a functional restoration program (FRP) in chronic low back pain, and then to compare the effectiveness of FRP depending on the rate of people returning to work, the acceptability threshold of pain has been reached or not at the end of the program.

Method

Open prospective study on 303 patients with chronic low back pain included in a FRP. An assessment of the deficiencies (finger-tip-to-floor (cm) and Schöber tests (cm), VO2 max (l/min), Shirado and Sorensen tests (seconds), lumbar and radicular VAS (0-100), the functional disability (Wadell and Quebec scales (0-9 and 0-100), and the psychological status (Beck and Hamilton scale (0-35 and 0-30), HAD scale (0-21), FABQ (0-42 and 0-24)) was conducted at the beginning and end of the program. Data on the work were also collected (arduous physical labor, work-related accident or not, sick leaves or not and length, return to work at the end of the program). The variables associated with a PASS at the end of the FRP and a correlation between the level of pain and the return to work were sought.

Results

The parameters were significantly improved : finger-tip-to-floor test (−17,5 ± 16,2), Schöber test (−0,5 ± 5,4), lumbar VAS(−6,3 ± 23,6), VO2 max (0,14 ± 0,4), Wadell (−1,3 ± 2,4), Quebec (−10,5 ± 17), Beck D (−3,1 ± 4,5), Beck A (−2,5 ± 4,3), HAD D (−2,4 ± 4,7), HAD A (−1,3 ± 3,8) et FABQ1 (−5,7 ± 11,6), FABQ2 (−3,9 ± 9,6) scores, endurance of the flexor (35 ± 63,83) and extensor (44,8 ± 112) spine. Patients reaching the PASS for pain level return significantly more to work (73% versus 52%). Five parameters indicative of a reduction of back pain under the PASS were identified : lumbar VAS and endurance of the flexor spine at the beginning, changes in finger-tip-to-floor test, radicular VAS and Beck score for anxiety.

Conclusion

The PASS appears to be a relevant concept associated with a successful return to work for patients with chronic low back pain and severe disability after a program of FRP.     

Le traitement des fractures comminutives de l’extrémité distale du radius par fixateur externe : à propos de 18 cas

Comminuted fractures of the distal radius are common. A retrospective study was conducted in the department of orthopaedic trauma-A of university hospital Hassan II of Fez on a six-year period between January 2005 and December 2010 involving 18 cases of comminuted fractures of the distal radius treated with distraction external fixator. The average age of our patients was 28 years old, all male, all of our patients had a wrist injury during a sports accident. The right side was affected in 88 % of cases. X-rays have objectified an articular fractures and/or comminuted without opening the skin, we adopted the Castaing classification stadifier for fractures of the distal radius. The treatment consisted of a bipolar distraction external fixator combined with a plug-in three patients, ablation of osteosynthesis material was carried out in 6 weeks, then physical therapy was started. After falling 21 months, our results were very satisfactory with good recovery of mobility of wrist and back of any sport.     

Arrachements des épines iliaques antérosupérieures et antéro-inférieures chez l’enfant et l’adolescent sportifs. À propos de dix cas

The avulsions of anterior-iliac spines in child and adolescent athletes are rare injuries. All children have been treated as orthopaedic with strict rest, nonsteroidal anti-inflammatory substances and dispensation of sport for three months. No subsequent sequelae has been reported, all patients who got back to a sporting activity identical to that practiced before accident. It seems that the orthopaedic treatment among adolescents and children victims of avulsions of anterior-iliac apophysis, superior or inferior, is sufficient and does not involve any subsequent sequelae.     

Faux anévrisme de l’artère sous-clavière compliquant une fracture de la clavicule

The post-traumatic false anevrisms of the subclavian artery are rare; they exceptionally occur in a context of sports injury. They are, in most cases, the consequence of an artery pinning due to fractured clavicle. Both painful mass and traumatic history make the clinical diagnosis easier. The ischemic signs are rare and neurological ones reflect a brachial plexus injury. Doppler ultrasound and angiography have facilitated the procedures of diagnosis and contribute to the choice of the surgical approach and surgical tactics. Angiography as a diagnosis investigation is almost abandoned, but it triumphed among the ways of management once endovascular treatment is considered. Surgery remains the treatment of choice; it includes the flattening of the false aneurism, a restoration of arterial continuity and stabilization of clavicular fracture in the same operation. We report the case of a 30-year-old young man who, after a sport accident, had a fracture of the right clavicle with a false aneurism of the subclavian artery discovered 3 days after the trauma. He had received a flattening of the false aneurism and internal fixation with a clavicular bone plate with a favorable outcome. In this work, we remind the circumstances of occurrence, diagnostic and management therapeutic features of these rare lesions.