Use of botulinum toxin type A in symptomatic accessory soleus muscle: first five cases

Symptomatic accessory soleus muscle (ASM) can cause exercise-induced leg pain due to local nerve/vascular compression, muscle spasm, or local compartment syndrome. As intramuscular injections of botulinum toxin type A (BTX-A) can reduce muscle tone and mass, we investigated whether local BTX-A injections relieve the pain associated with symptomatic ASM. We describe five patients presenting peri/retromalleolar exertional pain and a contractile muscle mass in the painful region. Com-pression neuropathy was ruled out by electromyo-graphic analysis of the lower limb muscles. Doppler ultrasonography was normal, excluding a local vascular compression. ASM was confirmed by magnetic resonance imaging. After a treadmill stress test, abnormal intramuscular pressure values in the ASM, confirmed the diagnosis of compartment syndrome only in one patient. All five patients received BTX-A injections in two points of the ASM. The treatment efficacy was evaluated based on the disappearance of exercise-induced pain and the resumption of normal physical and sports activities. After BTX-A injection, exertional pain disappeared and all five patients resumed their normal level of physical and sports performances. Neither side effects nor motor deficits were observed. BTX-A is well tolerated in patients with ASM and could be used as a new conservative therapeutic strategy for the treatment of symptomatic ASM before surgery.

The value of nerve blocks in the diagnoses and treatment of complex regional pain syndrome type 1: a series of 14 cases

OBJECTIVES

Complex regional pain syndrome type 1 (CRPS-1) can progress to joint stiffness, which may be related to pain and/or capsule-ligament contracture. In this context, it is difficult to distinguish the respective causative roles of pain and contractures. Nerve blocks (NBs) can be used to determine the aetiology of joint stiffness. Subsequent treatment will depend on whether contractures are present or not. The objective of the present study was to evaluate the diagnostic and therapeutic value of the nerve blocks in the management of joint stiffness caused by CRPS-1.

DESIGN OF THE STUDY

A retrospective case series.

METHODS

Implementation of NBs in subjects with joint stiffness caused by CRPS-1. Primary efficacy criterion: an increase in the range of joint movement. Secondary criteria: pain level, treatment decision, duration of therapeutic NBs, return to work.

RESULTS

Fourteen patients with joint stiffness underwent 17 NBs. Ten NBs (59%) were associated with the normalization of the range of joint movement (i.e. the absence of contractures and the presence of an isolated pain component), prompting the implementation of physical therapy during NBs ("therapeutic NBs") in 90% of these cases. Three NBs (18%) were associated with a partial increase in the range of joint movement (i.e. a background of joint stiffness due to a combination of pain and contracture), prompting the implementation of a therapeutic NB in all of these cases. Four NBs (23%) were not associated with any increase in the range of joint movement (i.e. pure contractures), prompting consultation with a surgeon in all of these cases. Forty-three percent of the patients have since returned to work.

CONCLUSIONS

Nerve block is a valuable diagnostic and therapeutic option in the management of joint stiffness caused by CRPS-1.

Anterior cruciate ligament tear during the menstrual cycle in female recreational skiers

INTRODUCTION

Women run a 4-8-fold greater risk of anterior cruciate ligament (ACL) tear than men, and especially during the pre-ovulation stage of their cycle. The main study objective was to describe the distribution of ACL lesions according to menstrual cycle in a large population of female recreational skiers.

MATERIALS AND METHODS

A prospective study was conducted during the 2010-11 ski season on women sustaining ACL tear during skiing. Patients filled out a questionnaire during consultation with the mountain physician, including date of last menstrual period (LMP) and contraceptive method. Fifty-seven of the 229 patients with diagnosed ACL tear were excluded from analysis, 41 being post-menopausal (mean age, 47 ± 9 years), and 16 having irregular cycles or LMP>30 days. One hundred and seventy-two patients (mean age, 34 ± 8.7 years) were thus included.

RESULTS

Fifty-eight women (33.72%) were in follicular phase, 63 (36.63%) in ovulatory phase and 51 (29.65%) in luteal phase; difference with respect to the theoretic distribution regardless of menstrual phase was highly significant: χ(2)=48.32; P=0.00001. Fifty-three of the 172 women (30.8%) were taking oral contraceptives. ACL tear was 2.4-fold more frequent in pre-ovulatory than post-ovulatory phase, whether in women using oral or other contraceptives: 85/119 (71.4%) vs. 36/53 (67.9%); P=0.64.

CONCLUSION

ACL tear risk in skiing in women is not constant over the menstrual cycle, being 2.4-fold more frequent in pre-ovulatory (follicular and ovulatory) than post-ovulatory phase (luteal). Oral contraception seems not to exert any protective effect.

LEVEL OF EVIDENCE

Level IV. Retrospective cohort study.

Total knee arthroplasty in severe haemophilic patients under continuous infusion of clotting factors

PURPOSE

Haemophilic arthropathy is painful, invalidating and destructive. Authors report a prospective study of total knee arthroplasties in patients with severe haemophilia under continuous infusion of clotting factors. The purpose is to evaluate the benefits of continuous infusion of clotting factors regarding long-term functional improvement and radio-clinical results.

METHODS

From 1998 to 2009, 20 total knee arthroplasties were implanted in 14 patients with a mean age of 36.5 years (24-56). A continuous infusion of anti-haemophilic factors was used and supervised by the physician of the Regional Haemophilia Treatment Centre (CRTH). Evaluation was clinical using the HSS and Oxford scores and radiological.

RESULTS

One patient was lost to follow-up. Median follow-up is 66.5 months (6-134). Oxford score at latest follow-up is 42 (37-46). On revision, HSS score is 91 (84-96). Median flexion gain is 32.5° (-20; 75°). There is a median flexion contracture of 5° (0-15°) and a median extension improvement of 22.5°. We report 2 secondary infectious complications, concerning the same operated knee of a single patient. No post-operative haematoma was reported in our study.

CONCLUSION

Total knee arthroplasty in haemophilic arthropathy improves both the function and quality of life of this group of patients. Continuous infusion of clotting factors contributes significantly to these results, by allowing early and intensive rehabilitation, and offers security regarding haemorrhagic complications commonly described in the literature and that we have not encountered in our study.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.

[Secondary screening for osteoporosis in patients admitted for hip fracture to a rehabilitation center. Results of a survey]

GOALS

To determine prevalence, risk factors and treatment of osteoporosis in patients with hip fracture observed in a rehabilitation ward.

BACKGROUND

Hip fractures are associated with up to 20% excess mortality in the first year after fracture and cause functional disability in most survivors. Despite available risk indices and physician information, osteoporosis is still underdiagnosed and undertreated.

METHOD

We obtained history, clinical and biological data, and bone density (BD) data in 41 patients admitted with hip fracture to a rehabilitation care centre.

RESULTS

Only 3 patients had known osteoporosis. Although 50% had at least 1 clinical risk factor, all patients showed osteopenic BD scores and 68% had osteoporotic scores; only one was correctly treated.

DISCUSSION

As with international studies, our study shows that osteoporosis is underdiagnosed. Risk assessment tools allow for routine screening and preventive measures incorporated into standard care practice. The prevention of osteoporotic fracture can be promoted in rehabilitation centres.

Le muscle soléaire accessoire

PURPOSE OF THE STUDY

Well known to anatomy specialists, the accessory soleus muscle was first demonstrated to be involved in painful syndromes in 1965 (Dunn). This supranumerary muscle situated in front of the calcaneum can be taken for a soft tissue tumor. The purpose of this work was to report a series of 21 patients with an accessory soleus muscle and to present the characteristic features, diagnostic methods, and treatment indications and modalities.

MATERIAL AND METHODS

This series included 20 patients (one symptomatic bilateral case), fourteen men and six women, mean age 25 years. Seventeen patients practiced sports and ten had had a prior operation. All patients complained of exercise-related pain. The physical examination was normal with the exception of a tumefaction, which was soft at rest and hard at triceps contraction against resistance, lying laterally to the Achilles tendon. We studied plain x-rays, ultrasound studies, computed tomographies, and electromyograms and later MRI which became the reference method to demonstrate the details of normal muscle structure. Ten patients (one bilateral case) were not particularly bothered by the supernumerary muscle. Functional treatment was given and provided patient satisfaction. For the other ten patients, who wished to continue their physical activities, two underwent fasciotomy (including our first case where fasciotomy was undertaken because a tumor was suspected) and eight underwent resection of the supranumerary muscle.

RESULTS

The patients were followed for 6 to 19 years. Outcome was very good in all patients who were free of pain and had complete joint movement with symmetrical muscle force. Normal sports activities were resumed.

DISCUSSION

The accessory soleus muscle is found in 10% of individuals. It is often asymptomatic. The muscle inserts on the anterior aspect of the soleus muscle or on the posterior aspect of the tibia or the muscles of the deep posterior compartment. It lies anterior to the calcaneal tendon and terminates on the calcaneal tendon or the superior or medial aspect of the calcaneus via fleshy fibers or a distinct tendon. Frequent in primates, this anatomic variant is present during embryological development. Its persistence depends on phylogenetic evolution. Among other hypotheses (exercise-induced intermittent claudication, compression of the tibial nerve, excessive tension on the nerve innervating the accessory soleus muscle), this supranumerary muscle is generally considered to be the cause of a localized compartment syndrome. Pain experienced during exercise is the only symptom regularly reported by patients. A careful examination is required to rule out another local cause. Besides tumefaction lateral to the Achilles tendon, often found bilaterally, there is no other clinical sign. Plain x-rays, ultrasound and computed tomography simply demonstrate a "mass" in front of the Achilles tendon. MRI is the examination of choice enabling confirmation of the muscle nature of the mass and ruling out the possible diagnosis of tumor. Since there is no risk of aggravation, surgical treatment can be avoided if there is no complaint. If the patient is seriously impaired, surgery can be proposed. In our opinion, complete resection of the supernumerary muscle is the safest solution and should be preferred over simple fasciotomy.

Hypertrophie musculaire neurogène : à propos de trois cas, imagerie et revue de la littérature

OBJECTIVE

To review the literature on well-documented cases of neurogenic muscle hypertrophy in order to define significant features of this disease.

PATIENTS AND METHODS

The PUBMED and SCIENCE DIRECT web-sites were used to conduct an inventory of all reported cases of this disease. We entered the key-words "hypertrophy", "muscle" and "neurogenic", and found 48 articles, describing 129 cases. Our criteria of inclusion included hypertrophy of one or several muscles of a lower limb, previous realization of at least one imaging study (CT or MRI) and electromyography of lower limbs; criterion of exclusion was hypertrophy related to hereditary or acquired polyneuropathies. Twenty-five cases were retained for investigation along with 3 recent cases observed in our department.

RESULTS

Results show that neurogenic muscle hypertrophy is usually presents with painful enlargement of a calf in a male, aged 32 to 60 years, with previous history of low back pain and sciatica, 68% of the time due to disk herniation or lumbar stenosis. Other clinical findings may include radiation therapy or trauma.

CONCLUSION

The symptoms of neurogenic muscle hypertrophy may lead to MRI examination before electromyography. This disease should be included in the differential diagnosis.

Le syndrome de loge d'effort

OBJECTIVES

To review the literature on chronic exertional compartment syndrome.

METHODS

We searched the Medline database with use of the keys words compartment syndrome, exertional, chronic, pressure, and fasciotomy.

RESULTS

Exertional compartment syndrome is characterized by pain on exertion, which recedes at rest, and by excessive increase in compartment intramuscular pressure. Intramuscular pressure measurement is the reference diagnostic tool, but it has not been standardized or evaluated. Pressure observed during the first 5 min after exertion stops is more often used in diagnosis. The first studies of noninvasive investigations (magnetic resonance imaging, thallium single-photon emission tomographic imaging, near infrared spectroscopy) revealed their inadequate diagnostic value. The pathophysiological features of exertional compartment syndrome remain unclear: increased muscle bulk, fascia thickness and stiffness, stimulation of fascial sensory stretch-receptors, poor venous return, micromuscular injuries, and small clinical myopathic abnormalities. Treatment includes decreased sport activity or fasciotomy with partial fasciectomy. Several authors have used endoscopically assisted fasciotomy, which retrospective studies have shown to be successful. Long-term outcome studies could investigate the persistence of exertional minor pain and recurrence of the compartment syndrome with this treatment.

CONCLUSION

Further studies are required to understand the physiopathology, standardize the intramuscular pressure test and evaluate the pressure threshold values, evaluate noninvasive investigations and specify the long-term outcome of fasciotomy.

[An unusual complication of coronarography: neuralgia of the internal saphenous]

Many causes of saphenous nerve lesions at the knee or leg level have been reported. Proximal nerve lesions, especially after varicose vein stripping, are uncommon. We report a case of saphenous nerve lesion following catheterization of the femoral artery complicated with arterial spasm. The patient experienced pain for 10 years and only transdermal electroneural stimulation provided sedation. To our knowledge, this is the first published case of such an unusual complication after coronarography, despite the frequency of this procedure. We suggest nerve ischemia could explain the definitive neuralgia.

Knee joint arthroplasty in a patient with haemophilia A and high inhibitor titre using recombinant factor VIIa (NovoSeven): a new case report and review of the literature

Elective orthopaedic surgery is regularly withheld from patients with haemophilia and high inhibitor titre despite the presence of severe arthropathy and urgent medical need. A knee joint arthroplasty was performed in a patient with severe haemophilia A and a high inhibitor titre using recombinant factor VIIa (rFVIIa) as the sole coagulation factor. There was no abnormal bleeding during surgery although an increased blood loss through surgical drains did occur during the first 6 h postoperatively. Rehabilitation was started on day 1 and continued for 3 months. Walking commenced on day 4. After 1 year of follow-up, the clinical outcome of surgery was considered excellent with no pain, knee mobility at 0-5-90 degrees, and an International Knee Society score of 95/100. No rFVIIa-associated side-effects or thrombotic complications were reported. In conclusion, knee joint arthroplasty is now an option for haemophilia patients with a high inhibitor titre. An international review of all available data on elective orthopaedic surgery in inhibitor patients is required so that the optimal treatment regime can be defined and the short- and long-term risk-benefit ratio of surgery compared to that of noninhibitor patients.

Pseudotumoral osteochondromatosis of the hip in a soccer player

The authors present a case of pseudotumoral osteochondromatosis of the hip, interesting for its clinical and radiological features. They discuss the incidence of the sport in the pathogenesis of the loose bodies and the magnetic resonance findings.

[Polyneuropathy and neuromyopathy in intensive care. 4 new cases]

Neuromuscular complications acquired in the intensive care unit form a new clinical entity. Three neuromuscular deficits are described: so-called critical illness polyneuropathy where neuromyopathic changes are associated with corticosteroid and/or neuromuscular blocking agents, and catabolic myopathy. We report four new cases: three of them concerning polyneuropathy and one neuromyopathic change.

[Common low back pain and vertebral manipulations. Inventory. Evaluation, presumptive mechanisms of action. Problems]

Published data on the efficacy and presumptive modes of action of spinal manipulations are reviewed, as well as current problems with the technique. Although the best-designed studies have shown promising results, the efficacy of spinal manipulations has not as yet been firmly proven. The mode of action may involve mechanical changes in the disk and facet joints, but neurological mechanisms probably play the key role. Complications of cervical spinal manipulations are rare. To protect patients, French law requires that spinal manipulations be performed only by licensed physicians, who are the only professionals capable of establishing the accurate diagnosis before undertaking manipulations.

Improved antigenicity of the HIV env protein by cleavage site removal

The HIV env glycoprotein mediates virus infection and cell fusion through an interaction with the CD4 molecule present at the surface of T4+ lymphocytes. Although env presents a major antigenic target, vaccinia recombinants expressing env elicit low titres of anti-env antibody (Kieny et al., Bio/Technology, 4, 790-795, 1986). To delimit the functional domains of env and to improve the immunogenicity of the vaccinia recombinants we constructed variants expressing env proteins in which the site permitting cleavage of the gp160 precursor to yield gp120 and gp41 was removed, the gp120 and gp41 moieties separated or in which the signal sequence and hydrophobic domains were replaced by equivalents from rabies virus G. Analysis of variants revealed that the gp120 moiety is alone capable of interacting with CD4 and of provoking aggregation of T4+ lymphocytes, whereas cell-associated gp41 liberated by gp160 cleavage was essential for cell fusion. The identity of the signal and transmembrane zones however appeared unimportant. Although removal of the consensus sequence permitting cleavage of gp160 prevented syncytium formation but not aggregation of T4+ lymphocytes, significant cleavage continued to take place. Removal of a second potential cleavage site blocked gp160 cleavage. The live viruses were examined for immunogenicity: recombinant 1139 which lacks both putative cleavage sites was found to elicit a 10-fold higher antibody response in experimental animals than the parental recombinant.

[Plasma and synovial beta-2-microglobulin. Results of a personal study]

Beta-2-microglobulin was assayed in the plasma and the synovial fluid in 41 subjects with mechanical joint disorders, 27 patients with rheumatoid arthritis and 32 patients with non-rheumatoid arthritis. The plasma beta-2-microglobulin may be raised in all forms of joint disease, especially in the course of rheumatoid arthritis, but its ability to discriminate between rheumatoid arthritis and other forms of inflammatory joint disease is poor. In contrast, for the beta-2-microglobulin level in the synovial fluid, the differences in the means are highly significant between rheumatoid arthritis and non-rheumatoid arthritis. Concentrations of beta-2-microglobulin in the synovial fluid greater than 5.2 micrograms/ml, in this study which excluded patients with renal failure, were 100 per cent specific for rheumatoid arthritis and were found in 52 per cent of cases. However, this result has to be interpreted in the light of the fact that any extra-articular cause for an increased plasma beta-2-microglobulin, particularly renal failure, also causes a rise in the synovial concentration, invalidating the test. For this reason, the authors propose using the value of the beta-2-microglobulin in the synovial fluid minus the plasma beta-2-microglobulin, as a more specific index.

[Plasma and synovial fibronectin. Results of personal research]

The authors report the results of an assay of plasma fibronectin and synovial fluid fibronectin conducted in 104 patients with arthropathy, including 26 cases of rheumatoid arthritis, 43 cases of mechanical arthropathy and 35 cases of non-rheumatoid arthritis. The plasma fibronectin levels do not vary significantly between the different groups of patients, but the mean value for the whole group of patients is significantly lower than that of a control population. The mean value of synovial fluid fibronectin was significantly higher in the patients with rheumatoid arthritis (583 +/- 76 mg/1) than in the patients with non-rheumatoid arthritis (379 +/- 58 mg/1) or mechanical arthropathy (367 +/- 32 mg/1). The assay of synovial fibronectin could therefore provide useful information for the aetiological diagnosis of inflammatory arthropathies. The local origin, from the synovial membrane itself, of the fibronectin in the synovial fluid is suggested by the fact that the synovial concentration of this protein is superior to the serum concentration in 50 to 90 per cent of cases, depending on the disease.

[Open clinical trial of a new oral galenic form of ketoprofen]

Thirty-two patients with rheumatoid arthritis and several other rheumatic diseases were entered into a randomized study to investigate the correlation between the pharmacokinetics and clinical effectiveness of Bi-Profenid 150 mg. Each patient was given, in a variable order, one 150 mg Bi-Profenid tablet twice daily for 2 days, and two 50 mg Profenid capsules each morning and noon with one 100 mg suppository each evening for 2 days. Dosage convenience, effectiveness on pain during the second part of the night and resolution of morning stiffness were considered better with Bi-Profenid by 23 patients and with conventional forms by four, while five reported no preference. In 15 patients treated for one month, only 5 reported mild side-effects which did not require withdrawal from the study. The patients' preference appears to be a result of the bioavailability of Bi-Profenid.

[Etiologic aspects of Reiter syndrome. Role of yersinial infections (author's transl)]

Reiter syndrome occurs as a reaction to various infections, either by intracellular microorganisms (Chlamydia, Mlycoplasma) or by intestinal bacteria (dysenteric bacilli, Salmonella, Campylobacter, Klebsiella, Yersinia). Four personal observations of Reiter syndrome following yersinial infections (Yersinia enterocolitis in two cases and Yersinia pseudotuberculosis in the two other cases) are reported. Data concerning the yersinial etiology of Reiter syndrome are reviewed.

A bacterial RNA polymerase mutant that renders lambda growth independent of the N and cro functions at 42 degrees C

We describe a bacterial RNA polymerase mutation, rif 501, which confers rifampicin resistance and thermosensitivity to E. coli K 12. The purified RNA polymerase enzyme from rif 501 bacteria shows increased heatsensitivity in vitro at 51 degrees C. However, in vivo, at 42 degrees C the non-permissive temperature, mutant bacteria continue to grow and to synthesize RNA for 90 min. On a lawn of the mutant bacteria, at 40-41 degrees C, phage lambda forms clear plaques (LycA phenotype); this is probably due to an enhancement of cro function; we surmise that at 42 degrees C the transcription originating from the pR (but not from the pL) promoter on the lamdba genome becomes N-independent and less sensitive to the absence of the cro product. We discuss the possibility that both the N and cro proteins of phage lambda interact directly with the bacterial RNA polymerase. These observations indicate that the loss of viability of the rif 501 mutant at the restrictive temperature is not a consequence of an immediate inactivation of RNA polymerase; rather we feel it is due to a modification of the activity of RNA polymerase, leading to a disruption of the cellular regulation.

Illicit transport: the oligopeptide permease

The oligopeptide permease of Escherichia coli has been characterized by Payne, Gilvarg, and their colleagues. We have confirmed its existence in Salmonella typhimurium, and have isolated a series of mutants lacking the permease. We use this transport system for smuggling a histidine biosynthetic intermediate, histidinol phosphate ester, into the bacteria as its glycylglycyl derivative, Gly-Gly-histidinol phosphate. Free histidinol phosphate ester is not transported into Salmonella. Several amino-acid analogues are shown to be much more inhibitory to Salmonella when presented to the bacteria in the form of tripeptides than as the free amino acids. The implications of this work for practical purposes are discussed. The synthesis of Gly-Gly-histidinol phosphate is described.