Capsulite de l'épaule : évaluation d'une prise en charge combinée par arthrodistension et rééducation intensive (à propos d'une série de 39 épaules)

INTRODUCTION

Adhesive capsulitis is a clinical entity characterized by a loss of motion and a decrease of the joint volume capacity. Results of clinical trials have shown that distensions can help to decrease pain and increase the range of motion.

OBJECTIVE

The purpose of the study was to measure the effect of repeated distension arthrography combined with an intensive program of rehabilitation on pain, range of motion, and occupational outcome in patients with adhesive capsulitis.

DESIGN

39 cases of idiopathic capsulitis (7 cases) or secondary capsulitis (19 post-traumatic, 13 post-surgery of the rotator cuff) were included in the study. Intervention consisted of an intensive program of passive and active physiotherapy during one? Week and then distension arthrography, performed 3 times at 1- week intervals, with steroid injections in the glenohumeral joint and 1 in the subacromial space.

RESULTS

Lateral elevation improved substantially after the first week of physiotherapy and medial rotation after the first distension. Pain intensity decreased after the first distension. After the third distension, very small changes were noted. Results did not differ by etiology of capsulitis. At the end of the program, 9 of 17 patients could return to their previous job.

CONCLUSIONS

Two repeated arthrographic distensions with steroid injection and an intensive program of physiotherapy improves the range of motion and the painful condition associated with capsulitis and allows for a rapid return to employment. A third distension does not seem to provide a further benefit, as has been found by other studies.

[Camptocornia presenting with a proximal myotonic myopathy]

We report the case of a 74-year-old patient who presented with an anterior inflexion of the trunk which increased during the day. His past medical history included treatment for hypothyroidism, a cure of cataracts and an increase of gammaGT. This camptocormic attitude revealed a proximal myotonic myopathy (PROMM). Clinical and paraclinical arguments (hypothyroidism, cataracts, weakness, EMG, muscle biopsy, biology) led to diagnosis.

[Ulnar nerve tunnel syndrome of the elbow and an occupational disorder. Analysis of socio-professional and physical parameters]

PURPOSE

The ulnar nerve tunnel syndrome at the elbow is the second frequently tunnel syndrome, registered as an occupational disorder. The musculoskeletal troubles of the upper limb are now a public health challenge. These disorders allow manifold risk factors related to the work state, extrinsic to the patient, and related to individual factors, or intrinsic.

MATERIAL AND METHOD

In the same venture, 25 patients with a UNTS, declared as an occupational disorder, have been compared to 48 individuals (T). Intrinsic (physical and psychological) and extrinsic parameters have been evaluated by a questionnaire, physical examination completed by an investigation in the venture. The Nottingham Health Profile was performed by all the individuals.

RESULTS

All the cases of UNTS were observed after an increase of the production and a change in the work organization. Only 50% of the declared UNTS have a typical topography of the pain. No UNTS patient had neurological objective motor and sensitive deficit. 52% of the UNTS patients had diffused physical disorders comparatively to 17% of the T population. Stress events were observed more frequently in the UNTS population than in the T population: in the living area, in respectively 96% and 52% of the cases, at the work place in 12% and 2%. 50% of the UNTS population was distress comparatively to 17% of the T population. The NHP score was significantly higher in the UNTS population than the T population.

CONCLUSION

These data confirm the mutual influences of individual factors, physical and psychological, and of workplace factors in the occurrence of painful disorders related to an occupational activity. The therapeutic approach of these patients must be done with a physical, psychological and social evaluation.

Destructive hip disease complicating traumatic paraplegia

Recent progress in the management of spinal cord injury has provided longer survivals, and as a result the incidence of secondary bone and joint disorders has increased. Joint lesions due to syringomyelia complicating a cervical spinal cord injury are the most common of these disorders. We report a case of destructive hip disease 7 years after an injury responsible for complete paraplegia with sensory loss. The joint lesions were painless, and there was no local evidence of inflammation. Hip radiographs disclosed atrophic osteoarthropathy with complete destruction of the femoral neck and head. This unusual case raises questions about the pathophysiology of neuropathic osteoarthropathy in paraplegics.

Cervical spine involvement in psoriatic arthritis

The clinical and radiographic manifestations of cervical spine involvement in psoriatic arthritis remain incompletely described. Only one case-control study has been reported.

OBJECTIVE

To conduct a case-control study of the clinical and radiographic manifestations of cervical spine involvement in psoriatic arthritis.

PATIENTS AND METHODS

30 psoriatic arthritis patients (mean age, 53.3 years (21-78); sex ratio, 1; mean disease duration, 80.4 months (12-204); and mean Ritchie's index, 9.3 (2-30)) were compared with 30 controls with common low back pain (mean age, 53.8 years (21-78)). Each patient underwent a physical examination, completed a questionnaire on function, underwent cervical spine radiography (anteroposterior and lateral views and views in flexion and extension). All radiographs were evaluated by an independent observer.

RESULTS

Patients were more likely than controls to have neck pain (22/30 (73%) vs 8/30 (26%) P < 0.001). Among subjects with neck pain, the time pattern was more likely to be inflammatory in the patients than in the controls (14/22 vs 1/8, P < 0.001). Functional impairment and pain severity were significantly greater in the patients. On radiographs, facet joint abnormalities (osteophytes, joint space loss, sclerosis) were significantly more common (P < 0.01) in the patients, particularly at C3-C4 and C4-C5. Also more common in the patients were signs of spondylitis (7 vs 0) and of facet joint arthritis (7 vs 2). No subjects had syndesmophytes. Three (10%) patients had anterior C1-C2 subluxation with an atlas-dens interval greater than 4 mm. Within the patient group, no correlations were found between clinical patterns and radiographic findings.

CONCLUSION

Our data confirm that psoriatic arthritis frequently involves the cervical spine, with the facet joints being a preferred target, and can cause anterior C1-C2 subluxation.

[Serratus anterior muscle flap: indications and sequelae. 26 cases and review of the literature]

The authors report their experience of the use of the serratus anterior flap. Between 1992 and 1997, this flap was used for 14 head and neck and 11 limb and 1 intra-thoracic reconstructions. Twelve patients were examined for functional evaluation of the donor site. When only 2 or 3 slips are raised donor site morbidity is limited to moderate winging of the scapula with no functional disorders. Because of its thinness, and the length and diameter of the vascular pedicle, the serratus anterior flap is our favourite option for small wounds of the distal limb or composite and large defects in association with flaps of the subscapular system.

Influence of psychological factors on the response to clomipramine in hospitalized chronic low back pain patients. Preliminary data from a psychometric study

BACKGROUND

Chronic low back pain is a complex condition produced by multiple factors. Psychological disturbances have been found in previous studies using a variety of psychological tests. The most widely used self-administered questionnaire was the Minnesota Multiphasic Personality Inventory (MMPI).

OBJECTIVE

To assess the response to clomipramine in chronic low back pain patients according to baseline MMPI scores.

PATIENTS AND METHODS

Thirty chronic low back pain patients were given clomipramine intravenously during a ten-day hospital stay, then orally for 20 days. The dose was gradually brought up to 150 mg/d. The MMPI was administered on the day before treatment initiation. MMPI scores were not looked at until the end of the study. The Saint Antoine Questionnaire, a visual analog scale for pain, Schöber's maneuver, and the global result as assessed by the patients (success or failure) were evaluated on days 0 (D0), 4 (D4), 10 (D10), and 30 (D30).

RESULTS

The initial mean MMPI scores for hypochondria, depression, and hysteria were significantly lower in the 23 patients (76%) who considered their treatment successful on D30. Among the 13 patients with high hypochondria and hysteria scores, five improved during hospitalization then had a relapse after returning home.

CONCLUSION

The response to treatment with clomipramine was better in nondepressive patients. The hypochondria and hysteria scores were the best predictors of the response to clomipramine. These results may provide a basis for selecting those chronic low back pain patients most likely to benefit from clomipramine therapy.

Vessel patterning in the embryo of the zebrafish: guidance by notochord

We have cloned the zebrafish homolog of the receptor tyrosine kinase flk-1 to provide us with a tool to study normal vascular pattern formation in the developing zebrafish embryo and to compare it to mutants in which vascular pattern is perturbed. We find that during normal development the first angioblasts arise laterally in the mesoderm and then migrate medially to form the primordia of the large axial vessels, the dorsal aorta (axial artery) and the axial vein. Lumen formation occurs shortly before onset of circulation at 24 hr postfertilization. We examined the specification of vascular progenitors in the mutant cloche, which fails to form both vessels and blood. cloche lacks all flk-expressing cells and therefore appears to lack angioblasts. The axial vessels of the trunk form in close proximity to notochord and endoderm, which may provide cues for their formation. The dorsal aorta is normally just ventral to the notochord; the axial vein is just below the dorsal aorta and above the endoderm. floating head (flh) and no tail (ntl) mutants both have defects in the formation of notochord. Both are cell-autonomous lesions, flh abolishing notochord and ntl preventing its differentiation. In both mutants the dorsal aorta fails to form, while formation of the axial vein is less affected. Mosaic analysis of mutant embryos shows that transplanted wild-type cells can become notochord in mutant flh embryos. In these mosaic embryos flh cells expressing flk assemble at the midline, beneath the wild-type notochord, and form an aortic primordium. This suggests that signals from the notochord may guide angioblasts in the fashioning of the dorsal aorta. The notochord seems to be less important for the formation of the vein.

Mutations affecting the formation and function of the cardiovascular system in the zebrafish embryo

As part of a large-scale mutagenesis screen of the zebrafish genome, we have identified 58 mutations that affect the formation and function of the cardiovascular system. The cardiovascular system is particularly amenable for screening in the transparent zebrafish embryo because the heart and blood vessels are prominent and their function easily examined. We have classified the mutations affecting the heart into those that affect primarily either morphogenesis or function. Nine mutations clearly disrupt the formation of the heart. cloche deletes the endocardium. In cloche mutants, the myocardial layer forms in the absence of the endocardium but is dysmorphic and exhibits a weak contractility. Two loci, miles apart and bonnie and clyde, play a critical role in the fusion of the bilateral tubular primordia. Three mutations lead to an abnormally large heart and one to the formation of a diminutive, dysmorphic heart. We have found no mutation that deletes the myocardial cells altogether, but one, pandora, appears to eliminate the ventricle selectively. Seven mutations interfere with vascular integrity, as indicated by hemorrhage at particular sites. In terms of cardiac function, one large group exhibits a weak beat. In this group, five loci affect both chambers and seven a specific chamber (the atrium or ventricle). For example, the weak atrium mutation exhibits an atrium that becomes silent but has a normally beating ventricle. Seven mutations affect the rhythm of the heart causing, for example, a slow rate, a fibrillating pattern or an apparent block to conduction. In several other mutants, regurgitation of blood flow from ventricle to atrium is the most prominent abnormality, due either to the absence of valves or to poor coordination between the chambers with regard to the timing of contraction. The mutations identified in this screen point to discrete and critical steps in the formation and function of the heart and vasculature.

Vimentin in a cold-water fish, the rainbow trout: highly conserved primary structure but unique assembly properties

We have isolated from a rainbow trout (Oncorhynchus mykiss) spleen cDNA library a clone coding for vimentin. The deduced amino acid sequence reveals a high degree of identity with vimentin from carp (81%), frog (71%), chick and human (73% each). Large stretches in the central alpha-helical rod are identical within all four classes of vertebrates, but in 17 residues spread over the entire rod, the two fish differ distinctly from the tetrapod species. In addition, in the more diverged non-helical head domain, a nonapeptide motif previously shown to be important for regular filament formation is conserved. Recombinant trout vimentin assembles into bona fide filaments in vitro, with a temperature optimum between 18 and 24 degrees C. Above 27 degrees C, however, filament assembly is abruptly abolished and short filaments with thickened ends as well as structures without typical intermediate filament appearance are formed. This distinguishes its assembly properties significantly from amphibian, avian and mammalian vimentin. Also in vivo, after cDNA transfection into vimentin-free mammalian epithelial cells, trout vimentin does not form typical intermediate filament arrays at 37 degrees C. At 28 degrees C, and even more pronounced at 22 degrees C, the vimentin-positive material in the transfected cells is reorganized in the perinuclear region with a partial fibrillar appearance, but typical intermediate filament arrays are not formed. Together with immunoblotting and immunolocalization data from trout tissues, where vimentin is predominantly found in glial and white blood cells, we conclude that vimentin is indeed important in its filamentous form in fish and other vertebrates, possibly fulfilling cellular functions not directly evident in gene targeting experiments carried out in mice.

Infectious discitis diagnostic contribution of laboratory tests and percutaneous discovertebral biopsy

Clinical and laboratory findings in 120 patients with suspected discitis (loss of disk height and erosions of the vertebral endplates on plain radiographs) were reviewed and compared with percutaneous discovertebral biopsy results. Patients were categorized into three groups based on whether the symptoms developed after an invasive procedure (Group I), during septicemia (Group II), or spontaneously (Group III). Group II patients were more likely to have fever and had higher mean erythrocyte sedimentation rate and C-reactive protein values. A pathogen was recovered in the biopsy specimen in 34%, 60.7%, and 43.5% of patients in groups I, II, and III, respectively. Specific histologic changes were seen in 49%, 42.8%, and 51.3% of cases, respectively. The combination of clinical, laboratory test, and biopsy findings established the diagnosis of pyogenic discitis in 74 cases (62.5%), tuberculous discitis in nine cases (7.5%), and degenerative pseudodiscitis in 37 cases (30%). Percutaneous biopsy had a sensitivity of 72% and a specificity of 94%. Percutaneous discovertebral biopsy is helpful for the diagnosis of infectious discitis and should be done whenever this condition is suspected.

Behaviour of macroglial cells, as identified by their intermediate filament complement, during optic nerve regeneration of Xenopus tadpole

Assessment of glial cell behaviour during optic nerve (ON) regeneration in Xenopus tadpoles is hampered by the lack of classical cellular markers that distinguish different glial cells in mammals. We thus have characterized the intermediate filament (IF) complement of tadpole glial cells and used it to follow the fate of glial cell subsets during the first 10 days after ON crush. Glial cells synthesize a restricted number of cytokeratin (CK) species and vimentin. This pattern remains essentially unchanged during metamorphosis and regeneration. However, vimentin turnover is specifically enhanced after injury. The expression of CKs and vimentin has been followed immunocytochemically in situ and in isolated cells recovered from dissociated ON segments. In the normal nerve, 79% of ramified glial cells express both CK and vimentin, 1% CK and 4% vimentin only, whereas 16% express neither IF protein. We tentatively classified CK expressing cells as mature astrocytes and those without IF proteins as oligodendrocytes. In the regenerating ON, the relative number of oligodendrocytes is decreased, while the astrocytic subset becomes accordingly larger but is decreased by day 10 already in favour of cells expressing vimentin only. Astrocytes invade the lesion site soon after crush, arrange into a central core within the distal nerve segment and establish a peripheral scaffold that is readily crossed by axons. Unlike mammalian astrocytes that remain absent from the lesion site but form a scar at some distance to it, amphibian astrocytes appear to provide active guidance to axons growing through the lesion site.

[Automated percutaneous nucleotomy. Results in 50 patients]

Automated percutaneous discectomy was introduced by Onik et al. in 1985 for the treatment of lumbar disk herniation. Success rates have ranged from 42% to 86%. We evaluated efficacy and looked for factors with a bearing on outcome in a retrospective study of 50 patients. Patients who did not have subsequent surgery were evaluated at least six months after the procedure, using the criteria developed by Mac Nab and by Stauffer and Coventry. The procedure was successful in 31 patients (62%) and failed in 19 (38%). Thirteen patients with failed automated percutaneous discectomy required surgery. Severe disk degeneration was significantly predictive of treatment failure. Lumbar spinal stenosis was also associated with lower success rates. Two patients developed infectious discitis after the procedure. Automated percutaneous discectomy may be less satisfactory than nucleolysis. Further studies are needed to determine the role and efficacy of this method for the treatment of lumbar disk herniation.

[Injection into the lumbar vertebrae in chronic low back pain. Results in 206 patients]

Facet syndrome is an apparently common although not readily identifiable cause of low back pain. To evaluate the efficacy of corticosteroid facet joint injection for the treatment of low back pain, we retrospectively studied 206 patients with low back pain ascribed to facet syndrome. Effectiveness was evaluated on the basis of a clinical score and of a questionnaire completed 10 to 34 months after treatment. Success rate was 53.9% according to the clinical score (23.3% excellent results and 30.6% average results) and 41.74% according to the questionnaire. Results were better in patients who were not gainfully employed and had a negative history for occupational injury and surgical discectomy. Success rates in earlier studies varied from 22% to 76% in the short term and from 8% to 62% in the long term. These broad ranges denote substantial variations in evaluation criteria and patient selection. Only two placebo-controlled trials have been performed. There is a need for a prospective study with strict inclusion criteria and appropriate evaluation criteria taking quality of life into account to determine the role of facet joint injection in low back pain.

[Denervation of the posterior lumbar vertebral apophyses by thermocoagulation in chronic low back pain. Results of the treatment of 103 patients]

The facet syndrome seems to be a common cause of low back pain. Percutaneous radiofrequency lumbar facet denervation, developed by Shealy, may be of therapeutic value in facet syndrome patients. This method consists in thermocoagulation of the middle branch of the dorsal primary ramus of the spinal nerve. The authors report their experience with this technique in a retrospective series of 103 patients with chronic low back pain ascribed to facet syndrome. Results were evaluated after 6 and 24 months using a questionnaire and the Stauffer and Coventry classification. Among the 86 patients who completed the questionnaire, 38.4% considered the treatment successful, whereas 61.6% considered that it had not been of benefit. According to the Stauffer and Coventry classification, there were 20.9% excellent results, 22.1% fair results, and 57% failures. Results were better in those patients with a negative history for surgical discectomy. Success rates reported in the literature vary widely, from 14% to 76%. Interpretation of these data is difficult since studies used a broad range of treatment techniques, evaluation methods, and patient selection criteria. A prospective study using stringent inclusion criteria and appropriate evaluation criteria taking quality of life into account is needed to determine the role of percutaneous facet denervation among other treatment options available to low back pain patients.

The temporomandibular joint in rheumatoid arthritis: correlations between clinical and tomographic features

Clinical and radiological involvement of the temporomandibular joint (TMJ) in rheumatoid arthritis (RA) varies greatly in the literature. Clinical and tomographic (sagittal plane) examination of the TMJ was performed in 26 patients with RA and 26 control subjects. Sixty-one per cent of the RA group had physical signs in the TMJ, compared with 42% in the control group (NS). Sixty-nine per cent of the RA group had erosive or cystic lesions of the TMJ compared with 31% of control subjects (P < 0.01). The clinical dysfunction score did not correlate with the tomographic TMJ score in patients with RA. It was found that a wide range of tomographic abnormalities occurs in patients with RA and in patients without the disease, and that there are no tomographic abnormalities specific for RA; however, the incidence of erosions and cysts of the mandibular condyle are significantly higher in patients with RA (P < 0.01), and should suggest the diagnosis. It was also found that there is no correlation between the clinical and tomographic findings of the TMJ in RA, and that the intensity of destructive lesions of the TMJ on tomography in RA is well correlated to the severity of the disease (evaluated with clinical and laboratory features).

[Value of standard radiographies in the diagnosis of rotator cuff rupture]

To assess the value of the Leclercq maneuver (anteroposterior roentgenogram of the shoulder during resisted active abduction) for the diagnosis of rotator cuff tear, the medical records of 93 patients evaluated by glenohumeral arthrography, standard radiographs, and radiographs taken using the Leclercq maneuver were retrospectively reviewed. The comparison of patients with (n = 53) and without (n = 40) arthrographic evidence of rotator cuff tear demonstrated statistically significant differences for mean acromiohumeral space difference between the normal and affected shoulders, for the acromiohumeral space difference between the standard film and Leclercq maneuver film, and for presence of an inferior glenohumeral diastasis on the Leclercq maneuver film. An acromiohumeral space of 7 mm or less on standard radiographs proved a specific (0.975) but insensitive (0.24) sign of rotator cuff tear. This parameter measured on the Leclercq maneuver film exhibited better sensitivity (0.62) and excellent specificity. Other criteria with good specificity for rotator cuff tear included an acromiohumeral space difference between the normal and abnormal side of 2 mm or more (0.97), an acromiohumeral space difference between standard and Leclercq maneuver films of at least 4 mm, and existence of an inferior glenohumeral diastasis; however, sensitivities of these three parameters were poor (respectively 0.65; 0.20; and 0.19).(ABSTRACT TRUNCATED AT 250 WORDS)

Prenatal diagnosis of trisomy 9 mosaic presenting as a case of Dandy-Walker malformation

Trisomy 9 syndrome is a rare chromosomal anomaly associated with specific patterns of multisystem dysmorphism and occasional central nervous system (CNS) malformations, the most common being the Dandy-Walker malformation. Milder anomalies are usually seen with trisomy 9 mosaicism. We report what we believe to be the first case of a baby with an isolated Dandy-Walker malformation which was diagnosed prenatally and was subsequently found to have a trisomy 9 mosaic syndrome.

[Long-term results of chymopapain chemonucleolysis]

Results of chemonucleolysis were evaluated (on the basis of residual pain, occupational activities, physical activities, and use of analgesics) in 125 of 162 consecutive patients with lower back pain and sciatica associated with documented vertebral disc protrusion who were managed and followed up for at least five years. Results were satisfactory in 62% of patients. Among 82 patients evaluated during a follow-up visit, 30% were free of symptoms, 38% had lower back pain, and 30% had radicular pain; however, among symptomatic patients, 67% had no limitations of activities of daily living. Results were significantly less favorable in power drill workers and in patients who had chemonucleolysis at the L4-L5 level. These data are evidence that chemonucleolysis provides good long-term results.