Traitement des épiphysiodèses partielles traumatiques chez l'enfant par désépiphysiodèse

Résumé Cinq cas d'épiphysiodèse partielle post-traumatique ont été traités par désépiphysiodèse, à cause d'une déviation progressive.Dans le premier cas, une épiphysiodèse centrale de l'extrémité inférieure du tibia a provoqué un pied varus progressif. L'intervention a consisté en une résection du pont d'épiphysiodèse avec interposition de ciment acrylique dans le but d'éviter la récidive. Une ostéotomie de correction d'axe a été associée. Après 8 ans d'évolution, la croissance épiphysaire a permis un aspect et une fonction normaux, sans récidive.Un autre cas concernant une fermeture postérieure du cartilage de l'extrémité inférieure du fémur a été opéré de la même façon. Malheureusement, après une période favorable, il y a eu une récidive de la déformation due à une nouvelle fusion osseuse à travers la plaque.Trois autres cas ont été opérés en fin de croissance et sont moins démonstratifs.Ces cas sont en plein accord avec les récentes recherches expérimentales d'Osterman (1972) et laissent entrevoir des possibilités chirurgicales intéressantes.

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Treatment of traumatic partial epiphysiodesis in the child by epiphysiolysis

Summary Five cases of post-traumatic partial epiphysiodesis were treated by surgical epiphysial release because of progressive deformity.In the first case, central epiphysiodesis of the lower extremity of the tibia resulted in a progressive varus foot. Surgery involved resection of the bony bridge and interposition of acrylic cement in order to avoid recurrence. Corrective osteotomy was also performed. After 8 years of further epiphysial growth, normal shape and function were still present.In the next case, posterior fusion at the distal end of the femur head occurred and was similarly treated. Unfortunately, following an initial favourable period, further fusion across the growth plate occurred with recurrence of the deformity.Three other cases were operated on towards the end of the growth period and are less illustrative.These cases are consistent with the recent experimental research of Osterman (1972) and pave the way for interesting opportunities in the future.

A qui doivent tre adressées les demandes de tirés à part     

Über intravenöse Tierblutgaben in der Chirurgie

Zusammenfassung Wir besitzen in der intraven?sen Tierblutgabe nachBier ein Mittel, das geeignet ist — m?chtiger als jedes andere mir bekannte — für eine bestimmte Frist eine Besserung des Allgemeinzustandes zu erzwingen und dadurch in manchen F?llen den Kranken überhaupt erst operationsf?hig zu machen. Die Technik ist einfach. Es bedarf aber zur Erzielung guter Ergebnisse einer gewissen Erfahrung. Das Verfahren darf nicht als v?llig harmlos angesehen werden. Die Erheblichkeit des zu bek?mpfenden Leidens mu? mit dieser Tatsache im richtigen Einklang stehen.      

Chirurgie reconstructive après amputation traumatique du pouce

Secondary thumb reconstruction after traumatic amputation has largely evolved owing to the development of numerous techniques. Conventional techniques remain important and indicated, including the rejuvenated osteoplastic reconstruction with composite forearm island flaps and the progressive lengthening by distraction. Pollicization remains sometimes indicated, in case of associated mutilated finger. Microsurgery has been added to the armamentum through free vascularized toe transfers. Even in this field, improvements are observed, both for the recipient and the donor sites.     

Rapport Rein 2011 – Synthèse

Incident patientsIn 2011, in France, we estimate that 9 400 patients started a treatment by dialysis (incidence of dialysis: 144 per million inhabitants) and 335 patients with a pre-emptive graft without previous dialysis (incidence of pre-emptive graft: 5 per million inhabitants). As in 2010, incidence rate seems to stabilize. Elders provide the majority of new patients (median age at RRT start: 71 years old). New patients present a high rate of disabilities especially diabetes (41% of the new patients) and cardiovascular disabilities (>50% of the new patients) that increase with age. Considering treatment and follow-up, the first treatment remains center's hemodialysis and we do not notice any progression of self-dialysis. RRT started in emergency in 33% of the patients. This finding contrasts with the fact that 56% of patients started hemodialysis on a catheter. This, together with the major inter-region variability, suggests that different strategies of management exist. Finally, the hemoglobin level at RRT start seems to be an interesting indicator of good management and follow-up since 13% of patients presenting an underprovided follow-up have a hemoglobin level under 10 g/dl, whereas only 2.5% of patients with an appropriate follow-up presented such a condition.Prevalent patientsOn December 31, 2011, in France, we estimate that 70.700 patients were receiving a renal replacement therapy, 39.600 (56%) on dialysis and 31.100 (44%) living with a functional renal transplant. The overall crude prevalence was 1091 per million inhabitants. It was 1.6 higher in males.

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Renal replacement therapy for End-stage renal disease in 2011 in France

Prevalence was subject to regional variations with 5 regions (3 overseas) above the national rate. Renal transplant share varied from 33% in Nord-Pas de Calais to 53% in Pays de Loire, and from 16 to 25% in overseas regions. The study of temporal variations for 18 regions contributing to the registry since 2007 demonstrated a +4% increase in standardized prevalence of ESRD patients with a functional transplant vs. +2% increase for dialysis, resulting in a decreasing gap between dialysis and transplantation prevalence, due to an increase number of renal transplant and a longer survival of transplanted patients.The main dialysis technique was hemodialysis (93.3% of patients). Even if an important inter-region variability remains considering the choices of treatment, more than 50% of the patients are undergoing hemodialysis in a hospital-based incenter unit, and we noticed an increase in hemodialysis in a medical satellite unit with time whereas the rate of self-care hemodialysis decreases. The rate of peritoneal dialysis remains stable. When comparing guidelines to real-life treatments, 77.5% of patients receive adequate dose of treatment (12 H/week, KT/ V>1.2), the rate of patients with a hemoglobin blood-level lower than 10 g/dl and without erythropoietin treatment is 1.3%, which confirmed a good management of anemia. On the contrary, 34% of patients have a BMI lower than 23 kg/m² and only 23% have an albumin blood-level over 40 g/l, which underlines that nutritional management of ESRD patients can be improved.MortalityAge strongly influences survival on dialysis. Thus, one year survival of patients under age 65 is over 90%. After 5 years, among patients over 85 years, it is more than 15%. The presence of diabetes or one or more cardiovascular comorbidities also significantly worse patient survival. In terms of trend, we do not find significant improvement in the 2-year survival between patients in the cohort 2006–2007 and the 2008–2009 cohort. Cardiovascular diseases account for 27% of causes of death to infectious diseases (12%) and cancer (10%). Life expectancy of patients is highly dependent on their treatment. Thus, a transplant patient aged 30 has a life expectancy of 41 years versus 23 years for a dialysis patient.ESRD pediatric patientsIn 2011, the incidence and the prevalence of ESRD among patients under 20 years old remained stable at 8 and 53 per million inhabitants respectively. The first causes of ESDR remain uropathies and hypodysplasia followed by glomerulonephritis and genetic diseases. Considering the initial treatment, we found a high rate of hemodialysis and a low rate of peritoneal dialysis that is mainly used in younger children. In 2011, 31 preemptive transplantations were performed accounting for 27.7% of new patients. Finally, survival analysis confirm that younger children (under 4 years old) have the highest risk of death (88% survival rate at 2 years vs. 98% in patients over 4 years old) and that the treatment of choice remains the renal transplantation since it increases the expected remaining lifetime of 20 to 40 years depending on the considered age.TransplantationAccess to the waiting list is evaluated on a cohort of 51,846 new patients who started dialysis between 2002 and 2011 in 25 regions. The probability of first wait-listing was of 3.7% at the start of dialysis (pre-emptive registrations), 15% at 12, 22% at 36 and 24% to 60 months. Patient older than 60 had a very poor access to the waiting list, whatever their diabetes status was. Among 13,653 patients less than 60 years old, the probability of being registered was 11% at the start of dialysis, 43% to 12 months, 62% to 36 months and 66% to 60 months (median dialysis duration: 16 months). Seventeen regions with up to 5 years follow-up show an increase of 8 to 15% in pre-emptive registrations between 2007 and 2001, without change at 1 year.Access to kidney transplant is evaluated on a cohort of 53,301 new patients who started a renal replacement therapy (dialysis or pre-emptive renal transplant) between 2002 and 2011 in 25 regions. The probability of first kidney transplant was of 7% at 12, 17% at 36 and 21% at 60 months. 8,633 patients (16,2%) had received a first renal transplant within 14.7 month median time; 1,455 (2.7%) had received a pre-emptive graft. Among the 14.770 new patients less than 60 years old, the probability of being transplanted was of 21% at 12, 46% at 36 and 58% at 60 months (median dialysis duration: 42 months). When pre-emptive graft were excluded, the probability of being transplanted was of 5% at 12, 15% to 36 and 19% to 60 monthsFlow between treatment modalitiesAmong the 36.849 patients on dialysis at 31/10/2010, 79% were already on RRT at 31/12/2009. Respectively 91%, 85% and 93% of the patients on HD in-center, HD self-care unit and peritoneal dialysis were in the same modality of treatment the year before. Among the 29.758 patients with a functioning graft at 31/12/2010, 98% were already on RRT at 31/12/2009, 95% of them with a functioning graft.72%, 72% and 74% of the patients with in-center HD, out-center HD and self-care unit were in the same modality of treatment at 31/12/2011. But 37% of the patients on PD at 31/12/2010 were not on PD at 31/12/2011. In 2011, new patients represented 89% of the entries in peritoneal dialysis. Renal transplantation represented 10% of the outcomes of the HD patients in self-care unit or at home.     

Die Bedeutung der Thymusdrüse für die Chirurgie

Ohne Zusammenfassung     

Prothèse de genou à charnière "AXEL"

Résumé L'AXEL est une prothèse à charnière qui présente deux caractéristiques essentielles. Elle autorise une rotation limitée qui supprime les contraintes rotatoires au niveau des tiges et améliore la stabilité rotulienne. Elle assure, du fait de l'appui permanent des condyles sur les plateaux polyéthylène, une bonne dispersion des contraintes qui limite l'usure des axes. Une série homogène de 142 prothèses de genou AXEL a servi de base à cette étude. Les indications sont celles de toute prothèse à charnière : les grandes déviations, les instabilités majeures, les raideurs serrées et les changements de prothèse. Les résultats sont analysés sur les 108 malades survivants, tous revus, totalisant 129 interventions avec un recul moyen de trois ans. On ne note dans cette série aucun accident per opératoire lié au scellement. Parmi les complications post opératoires, il faut retenir deux sepsis tardifs, une détérioration importante de l'axe, un descellement aseptique et quatre problèmes d'instabilité rotulienne. Toutes ces complications ont fait l'objet d'une réintervention, avec un sepsis residuel et deux rotules qui restent instables. La récupération fonctionnelle est toujours rapide et de bonne qualité quel que soit l'état pré-opératoire. La simplicité technique, l'absence d'accidents per opératoires ont conduit à proposer cet implant à des malades de plus de 80 ans qui représentent dans cette série 24 % des indications. Il apparaît en effet qu'à cet âge, en l'absence de risque particulier lié au type d'implant, la qualité et la rapidité de la récupération fonctionnelle priment largement sur l'importance du sacrifice osseux.     

Appareillage des membres inférieurs chez l’amputé diabétique : prothèse et chaussures

Objective

To evaluate the equipment specificities of diabetic lower limb amputees.

Judging criteria

Compare residual limb prosthesis, equipment of the other foot, and walking performances in diabetic and non diabetic above foot amputees.

Materials and methods

Direct inclusion of 31 patients.

Results

Diabetic amputees need 53 % more bilateral fittings than others—walking prosthesis on the amputated side and therapeutic footwear on the other side — because of foot trophic disorders (53 % more). There is no significant difference for other criteria.

Discussion

There are only a few differences between diabetic above foot amputees and non diabetic above foot amputees when prosthesis and walking performances are compared. Therapeutic footwear is often necessary in diabetic lower limb amputees — that is why systematic foot evaluation is needed in this population. This Caribbean study showed that it may be a lack of diabetic foot care in patients that led to amputation of the foot.

Conclusion

Diabetic above foot amputees need walking prosthesis and therapeutic footwear, but the diabetes has little impact on prosthetic choice and walking performance.