[Postexercise duplex ultrasound to diagnose external iliac endofibrosis]

Arterial endofibrosis is a disease of recent discovery which concerns high-performance athletes, predominantly competitive cyclists. The preferential location is the external iliac artery. The symptoms are diverse (pain, edema, paresthesia), always linked to an effort. The diagnosis may be delayed due to atypical symptoms in athletes. Complementary tests are measure of the systolic pressure index after exercise, duplex ultrasound, CT angiography, MR angiography and arteriography. We report a case of endofibrosis where late diagnosis was established with postexercise duplex ultrasound, while CT angiography and arteriography failed to reveal characteristic abnormalities.

Comparative study of clinical and ultrasonographic evaluation of lateral collateral ligament sprains of the ankle

AIM

Clinical examination is sometimes insufficient to assess the severity of lateral collateral ligament (LCL) sprain of the ankle, making it difficult to choose the most appropriate treatment. The aim of this study was to compare the assessment of clinical signs and the ultrasonographic findings in recent LCL sprain of the ankle.

METHODS

This was a retrospective cross-sectional study. Spearman's rank correlation test and multiple regression analysis were used to assess correlations between clinical signs and type of ligament injury. Fisher's linear discriminant analysis was used to determine most contributive signs in ligament tear diagnosis.

RESULTS

No single clinical sign was correlated with the severity of ligament injury as revealed by ultrasonography in the 34 patients analyzed. Careful assessment of all the usual clinical signs of severity seems to better guide the diagnosis of the presence or absence of ligament tearing.

CONCLUSIONS

These results confirm the lack of correlation between clinical examination and the anatomic injury in distension or partial tearing of the anterior talofibular ligament. They raise questions about the usefulness of clinical classifications and suggest a broadening of the indications for ultrasonographic exam in ambiguous situations, particularly for athletes showing few signs of severe injury, in order to ensure optimal treatment and a faster recovery.

Orthopedic shoes improve gait in Friedreich's ataxia: a clinical and quantified case study

Our aim was to evaluate with modern tools the efficacy of orthopedic shoes on gait disorders in Friedreich's ataxia. The case of a 26-year-old woman with Friedreich's ataxia is described. She mainly complained of fatigability, ankle instability, frequent falls and pain. Impairments involved a cerebellar syndrome, a proprioceptive deficit, an upper motor neurone syndrome and osteoarticular deformities. Gait disabilities included ataxia and requirement of a cane. Handicap concerned outings, altering quality of life. Orthopedic shoes combined with physical therapy were prescribed. Assessment of treatment was planned after one month. Self-assessment by the patient was noted. Clinical assessment was provided by physical examination and clinical gait analysis supported by video. Quantified assessment was performed with a Gaitrite system recording spatiotemporal gait parameters. Our results demonstrated that orthopedic shoes improved gait disorders in this patient with Friedreich's ataxia. Pain decreased, walking distance increased, falls were less frequent, going out became possible, stability was better, speed, step length and cadence increased. Both clinical and quantified assessment confirmed functional improvement felt by the patient. In conclusion complete medical and social assessment determines quality of prescription in physical and rehabilitation medicine.

Influence sur le contrôle postural du traitement par toxine botulique chez les sujets cérébrolésés

OBJECTIVE

To investigate modification of postural control after treatment with botulinum toxine in leg muscles of stroke patients.

METHODS

We performed a retrospective study of stroke patients who benefitted from injection of botulinum toxine in leg muscles between June 2003 and October 2004. The assessment before and after the injection relied on clinical examination and on posturographic recording on 2 force plates with the patient standing, with eyes open performing or not a double task consisting of an arithmetic test and with eyes closed. We also compared patients to healthy subjects.

RESULTS

Eight patients were included in the study. Botulinum toxine injection in the leg muscles significantly decreased the triceps spasticity, with no change in clinical assessment of balance control (Fugl-Meyer scale). The posturographic data show a decrease in the area of centre of pressure displacement in the double-task situation after the injection.

CONCLUSION

Thanks to the posturographic recording in the double-task situation, we showed a modification of postural control after treatment with botulinum toxine in leg muscles of stroke patients.

Orthopaedic shoes improve gait in a Charcot-Marie-Tooth patient: a combined clinical and quantified case study

The aim of this study was to assess the extent to which orthopaedic shoes improved gait in a patient with Charcot-Marie-Tooth (CMT) disease and to show how the latest gait analysis tools available can help to assess and quantify the efficacy of this treatment. The case of a 55-year-old woman with CMT disease is described. She complained mainly of pain and frequent falling. The physical examination and the clinical gait analysis showed the presence of bilateral foot drop, high-stepping and varus. Treatment based on physical therapy and orthopaedic shoes was prescribed. In order to assess the clinical efficacy of the treatment, a complete physical examination was carried out after the patient had been wearing the orthopaedic shoes for one month. The quantified assessment was performed with a Gaitrite system, which can be used to record the spatio-temporal parameters of gait. It was concluded that orthopaedic shoes provide specialists in physical and rehabilitation medicine with an excellent means of treating gait disabilities in patients with CMT disease. With the made-to-measure orthopaedic shoes used, the falling and pain disappeared; the patient's walking speed increased and the foot support base decreased in size. Both the clinical and quantified data confirmed the subjective improvement perceived by the patient. The latest tools available for performing quantified gait analysis in clinical practice provide useful means of objectively assessing the success of treatment.

[Temporal, kinetic and kinematic asymmetry in gait initiation in one subject with hemiplegia]

OBJECTIVE

To investigate the temporal, kinetic and kinematic asymmetry of gait initiation in one subject with hemiplegia with an equinus varus foot.

MATERIAL AND METHODS

A kinetic analysis with two AMTI force plates and a kinematic analysis with an ELITE optoelectronic system of gait initiation were performed in one subject with hemiplegia.

RESULTS

The duration of the gait initiation phases was asymmetrical. The monopodal phase was shorter when the affected lower limb was supporting than when the healthy one was supporting. The propulsion resulted from the force exerted on the healthy lower limb. The distribution of body weight on the lower limbs was asymmetrical. Body weight support was more important on the healthy side than on the affected side. Maximal extension of the ankle on the hemiplegic side occurred during the swing phase. Ground clearance was increased by elevating the knee higher on the affected side than on the healthy side during the swing phase. Initial contact with the floor was performed with the foot flat on the affected side.

CONCLUSION

This preliminary study has shown that gait initiation in one subject with hemiplegia was asymmetrical in kinetics and kinematics. The results concerning kinematics have not been reported previously for gait initiation in subjects with hemiplegia. The study of gait initiation should allow for better understanding postural and movement control strategies developed by patients with hemiplegia.

Analyse de la posture et du mouvement et médecine du sport

The use of posture and movement analysis methods has developed during the past 15 years. These methods are of special interest in the field of sport sciences and have allowed to improve the understanding of physiology of posture and movement in athletes. More recently these methods have been used in the field of sport medicine. In some cases, they have helped to identify abnormalities which cannot be seen on standard clinical examination and to understand the mechanism of lesions occurring during sport activities. For the future these methods should provide useful information for understanding the physiopathology of lesions, for developing prevention of pathologies related to sport and for elaborating and assessing new treatment protocols in the field of sport medicine.

[Heterotopic ossification and brain injury]

OBJECTIVES

The aim of the study was to evaluate the incidence and the risk factors of heterotopic ossifications in patients with severe traumatic brain injury.

MATERIAL AND METHODS

This retrospective study was conducted in a sample of 86 patients during a two years period. These patients were receiving care in an acute rehabilitation setting designed for traumatic brain injury patients emerging from coma. The statistical analysis used chi(2) and Fisher tests.

RESULTS, DISCUSSION

Forty-nine heterotopic ossifications were observed in 24 patients (incidence 28.57%, 2.04/patient). Most of them were localised at the level of the hip, of the elbow and of the knee. No significant relation was found between heterotopic ossification and sex, age, clinical severity, motor impairment, spasticity or autonomic dysreflexia. On the contrary, associated limb fractures, specially when requiring a surgical treatment, were found to be correlated to a greater incidence of heterotopic ossification.

CONCLUSION

Some of the risk factors observed in the present study were in accordance with those previously described in the literature. This work shows the difficult place of the initial care of patients with severe traumatic brain injury specially during there stay in intensive care units.

Reorganization of equilibrium and movement control strategies after total knee arthroplasty

This work was aimed at identifying changes in posturomotor control strategies in patients with unilateral total knee arthroplasty. Using kinetic and kinematic data, a previous study had revealed that, during a side step, patients with unilateral knee arthritis showed a shortened monopodal phase and a lengthened postural phase when the affected leg was the supporting one. It was expected that these strategies would be modified after undergoing total knee arthroplasty. Postoperatively the durations of the monopodal phase and of the postural phase became similar when the operated limb was supporting and when the sound limb was supporting. Concerning the upper body movements, the same asymmetrical results as before surgery were observed. Hence, patients with total knee arthroplasty exhibit posturomotor strategies which, although they become close to normal, remain asymmetrical. The durations of the monopodal and of the postural phases could be considered to assess the results of total knee arthroplasty.

Equilibrium and movement control strategies in trans-tibial amputees

This study was aimed at identifying changes in equilibrium and movement control strategies in trans-tibial amputees (TTA) related to both the biomechanical changes and the loss of afferent inflow. The coordinations between equilibrium and movement were studied in traumatical TTA and in controls during transition from bipedal to monopodal stance. TTA failed to perform the task in a high percentage of trials both when the sound and the prosthetic limb were supporting. Significant differences were also found between TTA and controls in the duration of the weight transfer phase, in the length of the initial centre of pressure (CP) displacement and in the electromyographic (EMG) patterns. Despite adaptive posturomotor control strategies, transition from bipedal to monopodal stance remains a difficult task to perform for TTA, both when the supporting limb is the affected one and when the sound one is. The results of this study are discussed with respect to the rehabilitation programme and the prosthesis design for transtibial amputees.

Asymmetry of gait initiation in patients with unilateral knee arthritis

OBJECTIVE

To identify how patients with knee arthritis modify their equilibrium and movement control strategies during gait initiation.

DESIGN

Observational study.

SETTING

University hospital movement analysis laboratory.

PARTICIPANTS

Twelve patients with unilateral knee arthritis and 12 healthy control subjects.

MAIN OUTCOME MEASURES

Durations of the phases of gait initiation (ie, postural, monopodal, and double-support phases), center-of-pressure displacements, ground reaction forces, pelvic velocity, step length, and knee range of motion were measured using a movement analysis system and force plates.

RESULTS

Gait initiation was slower in patients than in controls no matter which leg was the supporting one. In patients, the durations of the postural and the monopodal phases were modified in an asymmetrical way according to the leg used as the supporting one. The postural phase was lengthened and the monopodal phase was shortened when the affected leg was the supporting one. Opposite effects were observed when the sound leg was supporting. Step length, knee range of motion, and maximal pelvic velocity were reduced in patients whatever the side of the supporting leg.

CONCLUSION

Gait initiation is an asymmetrical process in unilateral knee arthritis patients, who develop adaptive posturomotor strategies that shorten the monopodal phase on the affected leg.

[Isokinetic comparative study at the third postoperative month after surgery of the anterior cruciate ligament with arthroscopy or after mini-arthrotomy]

PURPOSE

A double blind prospective study was performed in 64 patients with a clinical and isokinetic assessment three months after anterior cruciate ligament (A.C.L.) reconstruction.

MATERIAL AND METHODS

This work included 64 patients (47 males and 17 females), divided in two groups: 41 patients had an arthroscopically assisted bone-tendon-bone A.C.L. reconstruction, 17 had an open procedure. The isokinetic records concerned peak torque and muscular work at two different speeds.

RESULTS

Three months after surgery there was no significant difference between both groups particularly what concerns the isokinetic assessment in muscular performances. Peak torque in hamstring averaged 151.4 Nm in the open procedure group and 149.2 Nm in the arthroscopically assisted group (p = 0.7), in quadriceps 156.10 Nm vs 149.3 Nm (p = 0.47).

DISCUSSION

The advantages of arthroscopy in early muscular recovery are rarely admitted in medical literature.

CONCLUSIONS

The favorable opinion of the authors to the arthroscopically assisted A.C.L. reconstruction concerning its rapid muscular recovery abilities is only based on subjective criterions.

MRI of the intracranial corticospinal tracts in amyotrophic and primary lateral sclerosis

Our aim was to investigate the corticospinal tracts (CST) in motor neurone disease, using MRI, and to correlate findings with clinical data. We studied 31 patients with amyotrophic (ALS) and eight with primary lateral sclerosis (PLS). The signal from the CST was classified into four grades on T2-weighted images, and compared to T2-weighted images of 37 age-matched control subjects. No abnormalities were seen in the CST on T1-weighted images and were rarely evident on proton-density weighting. Variable high signal in the CST was found on T2-weighted images in 35 patients, and in 29 control subjects. Our grades 0 and 1 were more frequent in control subjects, grades 2 and 3 more frequent in patients. We found no correlation between the high signal and clinical data, including the duration of the illness. We therefore conclude that this technique is neither sensitive nor specific except in grade 3 which is quite specific for ALS. In half the patients we found atrophy of the superior parietal gyrus, which merits further study.

[Influence of knee replacement arthroplasty on modalities of weight transfer during the lateral step]

INTRODUCTION

The aim of this work was to study the relations between equilibrium and movement in patients after total knee arthroplasty. A previous study, conducted in patients with unilateral knee osteoarthritis, had shown that the timing of the events occurring during a side-step was modified in an asymmetrical way according to the supporting leg with respect to the affected one.

METHOD

A kinetic and kinematic analysis was performed in a population of 9 patients before and after total knee arthroplasty and in 11 control subjects, using an ELITE system and two AMTI force-plates. The different phases (i.e. postural, monopodal, landing and stabilization) of a side step were studied.

RESULTS AND DISCUSSION

Before surgery, the postural phase was longer and the monopodal phase was shorter in knee arthritis patients when the affected leg was the supporting one than when the sound leg was supporting. Total step duration and landing-stabilization phase duration were longer in patients no matter which leg was supporting than in control subjects. After total knee arthroplasty, the postural phase remained longer when the operated leg was supporting than when the sound leg was supporting. Altered proprioception can provide an explanation for this result. However, the duration of the postural phase decreased significantly when the operated leg was supporting as compared to when the affected leg was supporting before surgery. The duration of the monopodal phase was the same when the operated leg was supporting than when the sound limb was supporting and increased significantly as compared to when the affected leg was supporting before surgery. This result can be related to the decrease of pain which was observed in all patients after surgery. The duration of the landing-stabilization phase and the total movement duration remained longer in patients after surgery no matter which leg was supporting than in control subjects.

CONCLUSION

This study shows that relations between equilibrium and movement tend to become symmetrical with respect to the leg used as supporting one in patients after undergoing total knee arthroplasty but remain different from those of control subjects. This movement analysis method enables to determine and to quantify differences in patients before and after undergoing total knee arthroplasty and thus provides additional information for the functional evaluation of patients with total knee prosthesis.

Surgical management of calcific tendinitis of the shoulder: an analysis of 26 cases

Chronic calcific tendinitis of the shoulder has good results after medical treatment in most cases. Around 10% of the patients resistant to medical treatment require surgery. We report 22 patients operated on using an open procedure. The operation included removal of the calcific deposit and an acromioplasty. The patients were rated preoperatively and postoperatively for pain, limitations in activities of daily living, range of movement and power according to a questionnaire and the Constant assessment. Globally the average score increased from 52.2 points out of 100 at the preoperative examination to 89.3 postoperatively with a mean follow up of 23 months. The most favourable results are obtained in patients with the longest interval between onset of disease and intervention (over 1 year) and with a progressive course of disease. Different techniques are discussed. Arthroscopically assisted procedures and open techniques are compared.

Reorganization of equilibrium and movement control strategies in patients with knee arthritis

The purpose of this study was to identify changes in equilibrium and movement control strategies in patients with arthritis of the knee. These strategies were expected to be different from those of healthy subjects because of the impairments caused by knee arthritis. The different phases of a side step were studied in patients with severe knee arthritis using a movement analysis system and force-plates. The duration of the postural phase and the intensity of the horizontal ground reaction forces during the postural phase were increased when the pathological limb was the supporting one. The monopodal phase was shortened on the pathological leg. These results show that knee arthritis patients develop new posturomotor strategies mainly aimed at shortening the monopodal phase when the affected leg is the supporting one. This movement analysis method enables quantification of differences that cannot be observed on clinical examination between knee arthritis patients and control subjects, and provides additional information to the usual clinical evaluation scales.

Contrast-enhanced magnetisation transfer MRI in metastatic lesions of the brain

Our purpose was to compare prospectively the sensitivity of contrast-enhanced magnetisation transfer (MT) MRI and gradient-echo (GE) T1-weighted images in metastatic disease of the brain. We studied 52 patients with brain metastases, using conventional T1-weighted GE and MT spin-echo (SE) images after the same standard dose of gadolinium. Axial 5-mm reconstructions of GE data were compared with 5-mm MT images in the same plane. Metastases were counted independently by two neuroradiologists. In 12 patients (23%) MT imaging showed more metastases than GE images (P = 0.03). We detected 68 more metastases with the former technique.

[Methods of shifting body weight in patients with knee arthroses]

INTRODUCTION

The aim of this work was to study movement control strategies in patients with knee arthritis. These strategies were expected to be different from healthy subjects because of deficiencies due to knee arthritis (i.e. pain, altered proprioception).

METHOD

A kinetic and kinematic analysis was performed in a population of 10 patients with unilateral knee arthritis and in 11 age-matched control subjects, using an ELITE system and two AMTI force-plates. The different phases of a side step were studied.

RESULTS

The timing of the movement was different in the two populations. The postural phase was longer and the monopodal phase was shorter in knee arthritis patients when the affected leg was the supporting one than when the sound leg was supporting. Total step duration and landing-stabilization phase duration were longer in knee arthritis patients than in healthy subjects.

CONCLUSION

This movement analysis method enables to determine and to quantify differences between knee arthritis patients and control subjects. Clinical examination cannot identify these differences. Movement analysis methods bring up additional information to usual clinical evaluation scales and could be used for evaluation of the results of total knee arthroplasty.

Short-term evaluation of periradicular corticosteroid injections in the treatment of lumbar radiculopathy associated with disc disease

OBJECTIVES

The purpose of this study was to evaluate the feasibility and efficacy of periradicular corticosteroid injections performed under fluoroscopic guidance in the treatment of pain originating in the lumbosacral nerve roots.

METHOD

Forty patients presenting with lumbosciatica or femoral neuralgia unresponsive to conventional conservative treatment were admitted to the study. Patients with nerve root pain due to infectious, tumorous or inflammatory diseases were excluded, as were patients who needed immediate surgery. Pain was evaluated using a visual analog scale on the day of the injection and ten (D10) and ninety (D90) days later.

RESULTS

All patients were evaluated as scheduled on D10 and D90. The mean visual analog scale score decreased from 53.3 mm at baseline to 30.1 mm on D10 and to 21.8 mm on D90. Ninety per cent of patients had a visual analog pain score decrease on D10 and 85% on D90. Reported side effects were two cases of mild spontaneously regressive acne and one case of radicular pain exacerbation of less than one day's duration.

CONCLUSION

Periradicular injections of corticosteroids done under fluoroscopic guidance as an outpatient procedure was effective and safe in our study and may deserve to be used as part of the conservative management of lumbar nerve root pain before resorting to more invasive methods.

Short-term assessment of periradicular corticosteroid injections in lumbar radiculopathy associated with disc pathology

We evaluated periradicular injection of corticosteroids performed by neuroradiologists under fluoroscopic guidance in the treatment of lumbosacral nerve root pain in 40 patients (average age 48 years) presenting with lumbosciatica or radiculopathy not responding to conservative treatment. Patients with root pain due to infectious, neoplastic or inflammatory diseases were excluded, as were patients who needed immediate surgery. Pain was evaluated using a visual analogue scale (VAS) 10 and 90 days after the injection. After 10 days a substantial decrease in root pain was observed, with a statistically significant decrease in mean VAS. This decrease was observed in 90% of patients, and it persisted after 90 days in 85%. Side effects were rare, mild and disappeared spontaneously. They were related to the drug injected (corticosteroids).

Lyme disease presenting as isolated acute urinary retention caused by transverse myelitis: an electrophysiological and urodynamical study

Several neurological manifestations of Lyme disease, both central and peripheral, have been described. Reported here is a case of acute transverse myelitis related to a Lyme neuroborreliosis that presented with isolated acute urinary retention and no lower-extremity impairment. This case, documented by urodynamic and electrophysiological investigations, partially resolved after 6 weeks of intravenous ceftriaxone, affording the removal of the indwelling catheter. Alpha blocker therapy was needed for 3 months, until the complete normalisation of urodynamic and electrophysiological records. This case study indicates that whenever urinary retention is encountered associated with acute transverse myelitis or alone, the patient should be investigated for Lyme disease.