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.     

Embrochage percutané des fractures du col du cinquième métacarpien chez l’enfant et l’adolescent

Fracture of the neck of the fifth metacarpal (boxer's fracture) represents 20–50% of all fractures of hand and is frequently observed in young male adult, involve the dominant hand and result usually from a direct blow. This fracture is less common in pediatric population bur can occur in adolescent. We present a retrospective study of nine fractures of the neck of the fifth metacarpal, treated by percutaneous pinning. All the patients were boy. The mean age was 13.4 years (range: 11 to 15 years). Surgery was performed in cases of unstable fractures with a mean palmar tilt of 49° (range: 38 to 55°). Percutaneous pinning consisted of intramedullary K-wire fixation in four patients, intrafocal pining in three patients and elastic stable centromedullary nailing in two patients. After a mean follow up of 34 months, clinical and radiological results according to the criteria of Frère are good or excellent.     

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.     

L’embrochage centromédullaire élastique stable des fractures diaphysaires du tibia chez l’enfant

Surgical stabilization is rarely indicated for tibial fractures in children. The purpose of this study was to determine the importance and the complications associated with elastic stable intramedullary nailing (ESIN) in pediatric tibial fractures. We retrospectively reviewed 12 tibias in 11 patients that were treated by ESIN between 2000 and 2007 in our institution. Children ranged in age from seven to 14 years. There were ten closed and two open fractures. The average time union was 11 weeks. Four patients (36%) had five complications: one major (malunion > 10°) and four minors (1 leg length discreparancy < 12 mm, 1 superficial infection, 1 delayed union and 1 malunion < 10°). We believe that ESIN of pediatric tibia fractures is an effective treatment option.     

Traitement de la laxité latérale de cheville par ligamentoplastie à l’hémitendon du court fibulaire avec remise en tension capsuloligamentaire

The authors developed an original method, using tenodesis and anatomical repair, for the treatment of lateral chronic instability of the ankle in young military people. In this medium-term retrospective study, 32 patients were rewieved for functional and radiological evaluation. With a mean follow-up period of 20 months (range from six to 64 months), 90.6% (n = 29) of the patients were “satisfied” or “very satisfied”, 78.1% (n = 25) were painfree, but 15,6% (n = 5) complained about stiffness. Ninety-seven percent of them (n = 31) returned to athletic activity and no instability occured. The mean score for the Olerud and Molander Ankle Score was 91.5 (range from 70 to 100). On postoperative stress radiographs the mean side-to-side talar tilt difference was 0.6 ± 2.9°. The mean loosening of eversion isometric strength on the ankle operated was 5.4%. The present study demonstrates that this mixed procedure give excellent results in terms of stability, despite of a well-tolerated stiffness.     

Efficacité thérapeutique de l’autologous conditioned plasma (ACP™) : analyse de sa composition cellulaire et revue de la littérature

Purpose

To analyze the platelet counts of autologous conditioned plasma (ACP™) in a group of patients compared to that of whole blood and to determine the value of ACP™ based on a literature review.

Methods

In 2011, a prospective study was performed in a continuous series of patients presenting with chronic tendinopathies. Three 9 μL venous blood samples were obtained from each patient: the first to perform a full blood count and the second and third to prepare two doses of ACP™, one which was injected into the patient and the other which underwent biological testing. A bibliographic search was performed on PubMed with the key words “autologous conditioned plasma”. All studies both clinical and experimental, in English and in French, were included.

Results

The series included 14 male patients mean age 39 ± 14 years. The mean platelet count was 230,538.5 ± 23,663/μL in whole blood and 377,153.8 ± 69,169.9/μL in ACP™, P = 0.00015. The mean “ACP™ platelet count/whole blood platelet count” ratio was 1.64 ± 0.30. The number of red and white blood cells was below the detection thresholds. The systematic review identified eight studies: three in animals and five in human of which two clinical studies.

Conclusion

The preparation technique for ACP™ was rapid and easy to use. ACP™ had a platelet count that was significantly higher than that of whole blood and did not contain any red or white blood cells. The review of the literature did not clearly confirm the therapeutic efficacy of ACP™. Randomized clinical studies comparing ACP™ to placebo are needed.

Level of evidence

IV.     

Influence de l’anesthésie locorégionale sur la récupération musculaire après ligamentoplastie du genou

Anesthetic agents used for motor blocks have local toxic effects, demonstrated in vitro and in animal models. Little work has been done on the clinical impact of this toxicity. In a context of physical medicine and sports medicine, we examined several patients who had undergone knee ligamentoplasty for tears of the anterior cruciate ligament (ACL). For these patients, functional recovery was correlated with recovery of quadriceps strength. The purpose of this study was to analyze the impact of peripheral nerve blocks on quadriceps recovery at 5.5 months after knee ligamentoplasty.

Patients and methods

We conducted a retrospective analysis of 69 patients divided into three groups: 33 who had had no locoregional anesthesia (NB), 24 had femoral nerve block (FNB) and 12 had an iliofascial block (IFB). Our main outcome criterion was relative loss of quadriceps muscle force compared with the healthy side using isokinetic measures five to six months after ligamentoplasty. Isokinetic parameters were concentric Moment of Force Maximum (MFM) measured at 60°/s and 240°/s.

Results

Loss of concentric force at 60°/s was, on average: 24.7 ± 14.8% in group NB, 17.2 ± 13.9% in group FNB, and 19.7 ± 10.7% in group IFB. The difference between the three groups was not significant (P = 0.208). At rapid speed (240°/s) the deficit was on average: 23.111% in the group NB, 14.4 ± 10.5 in the group FNB and 13.4 ± 11% in the group FNB. The difference was significant only between NB and the two other groups, FNB and IFB. The quadriceps deficit was significantly greater in the patients who did not have a nerve block.

Discussion

Surprisingly, this study demonstrated result contradicting the initial hypothesis. Our finding showed that the local toxicity of anesthetic blocks did not have a negative clinical impact on muscle force, but that there was a positive effect on the quality of quadriceps recovery during the time studied. The conclusions of this retrospective preliminary study, with the resulting methodological limitations, must be re-evaluated with other work.     

Fracture de Mac Farland chez l’enfant. À propos de 15 cas

McFarland fractures are articular fractures of the ankle of the child, whose fracture line through the medial part of the growth cartilage of the lower end of the tibia. The treatment of these fractures remains problematic because of the risk of default or epiphysiodesis reduction intra-articular, with risks of malalignment and osteoarthritis. We report a series of 16 fractures including a bilateral McFarland collected over a period of six years between January 2004 and December 2009 in the service of trauma-orthopedic pediatric (CHU Hassan II of Fez). The average age of our patients was 12 years (five to 15 years) with female and eleven patients were operated: a screw in eight cases and a plug in three cases, the outcome was favorable with a mean of 23 months except for one patient who presented an epiphysiodesis.     

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.     

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.     

Fracture-avulsion de l’insertion tibiale du ligament croisé postérieur chez un enfant. À propos d’un cas et revue de la littérature

The isolated lesion of the posterior cruciate ligament (PCL) and in particular the tibial avulsion is a rarely reported entity on immature skeleton. We report a case of isolated avulsion fracture of the tibial insertion of PCL in a young athlete of 14 years old, treated surgically with good functional results 2 years later.     

Prise en charge des fractures récentes de la clavicule

Fractures of the clavicle are extremely frequent (2,6 to 5% of all the fractures). They typically occur in male children or young adults before 25 years. Because of anatomical particularity of the bone, these fractures are involving the middle third of the bone in 69% to 82% of cases. Satisfactory results are often achieved with an orthopedic treatment. However, in some cases, increasing risks of poor functional outcomes, higher risk of pseudarthrosis, ungraceful results or delayed work resumption lead to choose a surgical treatment. Many surgical procedures are described by authors to treat these fractures, but actually, there is no common consensus for surgical indication. The admitted shortening value for a surgical treatment is 20 mm. However, Altamini has shown the superiority of a surgical treatment in terms of functional results and decreasing cases of nonunion and pseudarthrosis in cases of fractures involving the middle third part of the bone.     

Évaluations prédictives de l’entorse de cheville. À propos de 58 cas

When an injury comes out, it is seen like a fatality for a sportsman and the medical staff. The ankle sprain is from far the most common pathology. Preventions programs proved their efficiency in many fields. However, it is very hard to put them into practice because there is few or no tools to these persons. The goal of this work is to provide assessments reliable, reproducible and non-dependent operator that will identify potential topics victim of a sprain ankle in the medium term. We tested 58 youngs healthy athletes whose sport practice was up to 2 hours a week. We have made assessments on a motor coordination machine, on a posturography platform and we analysed the muscular benefits of each lower limbs thanks to a accelerometer. These analyses have been done in November 2007, January 2008 and March 2008. We sorted out five articulars instability. Topics victims of the ankle sprain during the study got a 13% coordination deficiency. The difference is statisticly significant. All the tests which have been done on the postuography plateform were not accepted because the evaluation results were not comparables with the 1985 norms of the French Association of Posturology. We were able to see a curve problem with wounded patients during the ground absorbtion phase and had a stabilisation time shorter than the one for the healthy subjects. This significative difference was up to 110 ms. Pope et al. find out on patients hit by a talocrural sprain, a significative diminution of the dorsiflexion during the previous traumatism report. Willems et al. find these facts and describe others intrinsic factors of predisposition which match our results. Our work proved that it is possible to warn, in a mid term, the sprain of the ankle. These warnings reports must be done in the beginning of the sporting season and will allow to determine the athletes weakness thanks to reliable and reproducible evaluations.     

Facteurs de risque intrinsèques de tendinopathie patellaire chez le volleyeur. Étude prospective de 29 cas

Background

Patellar tendinopathy is a common and disabling injury among athletes, especially in sports with jumps such as volleyball.

Objective

The aim of this study was to determine intrinsic risk factors of patellar tendinopathy among young volleyball players.

Methods

This prospective study was conducted from August 2012 to April 2013. It included a clinical examination, ultrasound, muscle isokinetic assessment and tests of jumps at the beginning of the season, and then only a clinical examination at the end of the season. Athletes who developed patellar tendinopathy were compared to healthy subjects.

Results

Patellar tendinopathy (PT) group athletes (6) were older (17.2 ± 0.4 years vs 16.2 ± 0.9 years, P = 0.02) and had a stiffness of hamstrings higher (popliteal angle of 24 ± 12° vs 14 ± 9°, P = 0.04) than healthy athletes (16). They had an eccentric quadriceps peak torque at slow speed (30°/s) lower than healthy athletes (2.7 ± 0.2 Nm/kg vs 3.2 ± 0.5 Nm/kg, P = 0.05).

Conclusion

Age, stiffness of hamstrings and an eccentric strength deficit of quadriceps at slow speed (30°/s) would be intrinsic risk factors of PT among young volleyball players.     

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.     

La fracture de Tillaux chez l’enfant et l’adolescent. À propos d’une série de 11 cas

Background

Tillaux fracture in child correspond to Salter and Harris type III fracture involving the anterolateral portion of the distal tibial epiphysis. These are intra-articular fracture. The aim of this study was to analyze the therapeutic modalities and long-term clinical and radiological outcome.

Patients and methods

We reviewed retrospectively 11 Tillaux fractures. All underwent surgical treatment.

Results

The average age was 13.5 years. Patients were treated by open reduction and screw fixation. At mean follow-up of 28 months, results were rated well in nine of 11 cases.

Conclusion

The prognosis of Tillaux fracture in child is good as was observed in our studies and in series reported in the literature.     

Fracture ouverte de la clavicule et traitement par fixateur externe. À propos d’un cas et revue de la littérature

Introduction

Clavicular fractures are treated by orthopedic means or by surgery with internal fixation. Most open fractures are also treated surgically but the use of external fixator remains exceptional.

Clinical case

It is about a 23-year-old patient presenting secondary punctiform cutaneous opening within the framework of clavicule fracture. The fracture had remained exposed for more than 24 hours. After trimming of the wound and reduction, the stabilization of its fracture was carried out by an external fixator Percy Fx^®. The patient directly began rehabilitation for his upper limb. No infection was noted. On the third month, the callous was solid enough to allow hardware removal simple sedation.

Discussion

The cutaneous opening of the clavicule fractures is rare and represents less than one case over 1000. The open fractures in polytrauma patients are accompanied by other direct vascular, nervous even pulmonary complications. In the case of open fracture, surgery is indicated either by intramedullary nailing or with plate and screw fixation. However, the use of an external fixator is recommended by certain authors. The stabilization of this fracture was carried out by an external fixator whose flexibility, light character and radiotransparency, facilitated the follow up.

Conclusion

Although the installation of an external fixator remains exceptional for the treatment of an open clavicule fracture, this method could be under certain conditions an alternative technique to osteosynthesis.     

Intérêt de l’arthroscopie du genou dans le traitement du syndrome de la bandelette iliotibiale

Iliotibial band syndrome is a common cause of lateral knee pain in athletes. The diagnosis is clinical. Surgery can be proposed if well-conducted conservative treatment is unsuccessful for 6 months. We reviewed a retrospective series of seven patients at mean 3.7 years postoperative follow-up. Six practiced sports regularly. The preoperative work-up included a physical examination, standard X-rays and MRI of the knee joint and arthroscopy for all patients. Open surgery was performed with transverse section of the posterior fibers (10 mm). The outcome assessment was based on the pain score, the subjective IKDC score, and resumption of sports activities. Six patients had intra-articular lesions, which for three patients had been missed preoperatively. Arthroscopy was performed for complementary treatments in four patients. In 2008, six patients responded to a telephone interview. Outcome was very satisfactory: mean IKDC score was 84 in five patients who had resumed their sports activities at the same level. One patient underwent arthroscopy to rule out any intra-articular lesion causing lateral pain. Possible intercurrent conditions could be the cause of persistent pain despite adequate medical treatment and physiotherapy. Certain authors propose arthroscopic release. This option enables complementary treatments in the same operative time.     

Intérêt de la mosaicplasty dans le traitement des pertes de substances cartilagineuses focales : résultats anatomiques d’une série de dix cas

Introduction

The focal cartilaginous losses of the knee or the ankle in young patients raise essentially a therapeutic problem. The surgery is indicated to the unstable painful hurts in carrying arthrogenous zones. The mosaicplasty is a therapeutic option.

Purpose

Estimate the results of this medium-term technique.

Patients and methods

Our forward-looking series contains 10 cases interesting eight men and two women, middle-aged 32.5 years. Gene functional estimated by the score International Cartilage Repair Society (ICRS) was important in every case. The locations interested the knee in eight cases and the ankle in two cases (astragalien dome). The hurts were quite in carrying zone (zone 2: four cases, zone 4 and 5: three cases) according to the classification of Cahill and Berg and had an average area of 2.04 cm². Associated lesions were present in seven cases. The mosaicplasty was performed on average 29 months after the onset of clinical symptoms. The grafts used were 8 or 10 mm in diameter (1–4). The overall coverage is 78% (65–90%).

Results

The results were evaluated with a mean of 40 months. We have satisfactory functional results in 90% of cases and 80% of satisfactory anatomically results (control arthro-CT or MRI).

Conclusion

Our study and literature review confirms the efficacy and low morbidity of the technique of mosaicplasty in the treatment of cartilage defect from 1 to 3 cm².     

Avulsion de l’insertion fémorale du ligament croisé antérieur chez un adulte de 20 ans. À propos d’un cas

The cruciate ligament (ACL) injury is known in adults and his surgical treatment is often necessary. In addition, avulsion fracture of the ligament's tibial insertion especially interested. Indeed, only a few cases of avulsion or proximal femoral ACL have been reported and always concerned children. Through this article, the authors describe a rare case of femoral osteochondral avulsion fracture of ACL in a young adult of 20 years which followed a sports accident.