Johann Beaudreuil

Spinal tuberculosis in adults. A study of 103 cases in a developed country, 1980-1994.

Spinal tuberculosis (TB) accounts for about 2% of all cases of TB. New methods of diagnosis such as magnetic resonance imaging (MRI) or percutaneous needle biopsy have emerged. Two distinct patterns of spinal TB can be identified, the classic form, called spondylodiscitis (SPD) in this article, and an increasingly common atypical form characterized by spondylitis without disk involvement (SPwD). We conducted a retrospective study of patients with spinal TB managed in the area of Paris, France, between 1980 and 1994 with the goal of defining the characteristics of spinal TB and comparing SPD to SPwD. The 103 consecutive patients included in our study had TB confirmed by bacteriologic and/or histologic studies of specimens from spinal or paraspinal lesions (93 patients) or from extraspinal skeletal lesions (10 patients). Sixty-eight percent of patients were foreign-born subjects from developing countries. None of our patients was HIV-positive. SPD accounted for 48% of cases and SPwD for 52%. Patients with SPwD were younger and more likely to be foreign-born and to have multiple skeletal TB lesions. Neurologic manifestations were observed in 50% of patients, with no differences between the SPD and SPwD groups. Of the 44 patients investigated by MRI, 6 had normal plain radiographs; MRI was consistently positive and demonstrated epidural involvement in 77% of cases. Bacteriologic and histologic yields were similar for surgical biopsy (n = 16) and for percutaneous needle aspiration and/or biopsy (n = 77). Cultures for Mycobacterium tuberculosis were positive in 83% of patients, and no strains were resistant to rifampin. Median duration of antituberculous chemotherapy was 14 months. Surgical treatment was performed in 24% of patients. There were 2 TB-related deaths. Our data suggest that SPwD may now be the most common pattern of spinal TB in foreign-born subjects in industrialized countries. The reasons for this remain to be elucidated.

Contribution of clinical tests to the diagnosis of rotator cuff disease: a systematic literature review.

OBJECTIVE To evaluate the diagnostic performance of clinical tests for degenerative rotator cuff disease, based on a systematic literature review. METHODS We searched Medline, Embase, and Pascal Biomed until the first half of 2006 inclusive for articles that reported at least the sensitivity and specificity of clinical tests for rotator cuff disease. Predictive values and accuracy were recorded where available. The results were discussed and validated. RESULTS We selected nine studies, of which three investigated tests for subacromial impingement syndrome and seven tests for rotator cuff tendinopathy. The Neer and Hawkins tests had good sensitivity but low specificity for subacromial impingement syndrome. For diagnosing tears of the supraspinatus or infraspinatus, the Jobe sign and the full can test showed similar performance characteristics to the Patte test and resisted external rotation with the elbow at the side flexed at 90 degrees . For diagnosing tendinopathies with or without tears, active unresisted external rotation for the infraspinatus and the lift off test for the subscapularis were specific but lacked sensitivity. In one study, limitation of the range of active unresisted internal rotation was sensitive and specific for subscapularis tendon disease. The palm up test performed poorly for diagnosing long head of biceps disease. CONCLUSIONS Data on the diagnostic performance of clinical tests for rotator cuff tendon disease are fragmentary. However objective data exist to support the usefulness of some of these tests. Further studies are needed.

Clinical practice guidelines for rest orthosis, knee sleeves, and unloading knee braces in knee osteoarthritis.

OBJECTIVE To develop clinical practice guidelines concerning the use of bracing--rest orthosis, knee sleeves and unloading knee braces--for knee osteoarthritis. METHODS The French Physical Medicine and Rehabilitation Society (SOFMER) methodology, associating a systematic literature review, collection of everyday clinical practice, and external review by multidisciplinary expert panel, was used. RESULTS Few high-level studies of bracing for knee osteoarthritis were found. No evidence exists for the effectiveness of rest orthosis. Evidence for knee sleeves suggests that they decrease pain in knee osteoarthritis, and their use is associated with subjective improvement. These actions do not appear to depend on a local thermal effect. The effectiveness of knee sleeves for disability is not demonstrated for knee osteoarthritis. Short- and mid-term follow-up indicates that valgus knee bracing decreases pain and disability in medial knee osteoarthritis, appears to be more effective than knee sleeves, and improves quality of life, knee proprioception, quadriceps strength, and gait symmetry, and decreases compressive loads in the medial femoro-tibial compartment. However, results of response to valgus knee bracing remain inconsistent; discomfort and side effects can result. Thrombophlebitis of the lower limbs has been reported with the braces. Braces, whatever kind, are infrequently prescribed in clinical practice for osteoarthritis of the lower limbs. CONCLUSION Modest evidence exists for the effectiveness of bracing--rest orthosis, knee sleeves and unloading knee braces--for knee osteoarthritis, with only low level recommendations for its use. Braces are prescribed infrequently in French clinical practice for osteoarthritis of the knee. Randomized clinical trials concerning bracing in knee osteoarthritis are still necessary.

Unité Rhumatologique des Affections de la Main (URAM) scale: Development and validation of a tool to assess Dupuytren's disease–specific disability

To our knowledge, no functional outcome measure has been developed and validated for Dupuytrens disease. We aimed to develop and validate a patient‐reported functional outcome measure for Dupuytrens disease.

Bisphosphonates in bone diseases other than osteoporosis.

The range of bone diseases in which bisphosphonates are used has extended far beyond osteoporosis during the last few years. Bisphosphonate therapy is now so well validated as to be the reference standard in Pagets disease and in the prevention of bone complications related to malignant osteolysis. Promising preliminary findings warrant the use of bisphosphonates in conditions that are either rare (fibrous dysplasia) or severe (pediatric osteogenesis imperfecta). The third category of indications encompasses many conditions in which the limited available data do not warrant widespread use: examples include reflex sympathetic dystrophy syndrome, acute back pain after a vertebral crush fracture, and chronic inflammatory joint disease not treated by glucocorticoids.

Genetics of Dupuytren’s disease

Dupuytrens disease (DD) is a progressive fibrosis of the palmar fascia characterized by the formation of a nodule, which evolves into a cord. DD is the most common hereditary disease of the connective tissue preferentially affecting Caucasoids originating from Northern Europe. Some environmental factors are associated with DD, namely alcohol consumption, tobacco exposure and, possibly, manual activities. Diabetes and epilepsy are the most frequently reported DD-associated diseases. The genetic mode of inheritance is not well understood, but seems to be heterogeneous: most frequently, autosomal dominant with variable penetrance, and rarely recessive autosomal or maternal (matrilinear), suggesting a mitochondrial heredity. Initially, a suggestion of linkage with the DUPC1 locus at 16q was proposed. Then, among the genomic variations observed in DD, alterations in the copy number of genes in chromosomal regions 10q22, 16p12.1 and 17p12, associations with the HLA-DRB1*15 allele and a mutation in the rRNA 16s identified in forms with a matrilinear heredity, were reported. Finally, a genome-wide study has shown a genetic association of DD with 6, 11 and 16 chromosomes. Pathophysiology of DD involves mainly myofibroblasts and the extracellular matrix of collagen. Gene and protein expression studies have confirmed the central role of the β catenin of the TGFβ pathways in the pathogenesis of DD.

Needle aponeurotomy in Dupuytren’s disease

Needle aponeurotomy (NA) is recommended as a nonsurgical treatment for Dupuytrens disease. The aim of the procedure is to cut the Dupuytrens cord by use of the bevel of a needle and to restore full extension of the metacarpophalageal or proximal interphalangeal joints. According to Lermusiauxs standard, NA is performed in an outpatient setting, with the patient under local anesthesia. It entails the use of a 25-gauge, 16 mm-long needle and an anesthetic mixture of lidocaine and acetate of prednisolone. Various modifications have been proposed since the description of Lermusiauxs standard. Lermusiauxs and modified standards demonstrated structural efficacy in Dupuytrens disease. Clinical studies indicate that the mean rate of good structural results of NA is 80% at short-term assessment and 69% at 5-year assessment. Most of the studies are case series and only one is a randomized trial. Better results are demonstrated in early stages of the disease. NA also reduces disability and patients are highly satisfied. The short-term results with Lermusiauxs standard do not appear to be impaired in digital involvement. This is not the case for modified standards providing better results with palmar involvement. Lermusiauxs standard appears to provide less recurrences and less adverse events. In the largest study, skin fissure was observed in 8% of hands, transient dysesthesia in 3%, local infection in 0.7%, and flexor tendon rupture in 0.2%. Values were lower if related to NA sessions or NAs during each session. We therefore recommend Lermusiauxs standard for safe and effective NA in patients with Dupuytrens disease.

Assessment of dynamic humeral centering in shoulder pain with impingement syndrome: a randomised clinical trial

Objectives Treatment for degenerative rotator cuff disease of the shoulder includes physiotherapy. Dynamic humeral centering (DHC) aims at preventing subacromial impingement, which contributes to the disease. The goal of this study was to assess the effectiveness of DHC. Method 69 patients with shoulder pain and impingement syndrome were prospectively included in a single-centre randomised trial with a 12-month follow-up. Patients and assessor were blinded to the study hypothesis and treatment, respectively. DHC and non-specific mobilisation as control were performed for 6 weeks, in 15 supervised individual outpatient sessions, and patients performed daily home exercises. The planned primary outcome was the Constant score including subscores for pain, activity, mobility and strength at 3 months. Secondary outcomes were the Constant score and subscores at 12 months, and medication use for pain at 3 and 12 months. Results The DHC group did not differ from the control group in the total Constant score at 3 months. However, the DHC group showed a higher Constant subscore for pain (12.2 (SD 2.8) vs 9.9 (2.9), least square means difference 2.1, 95% CI 0.7 to 3.5, p=0.004). At 3 months, the DHC group also showed a higher rate of no medication use (96.7% vs 71%, proportional difference 25.7, 95% CI 3.7 to 51.9, p=0.012). There was no other intergroup difference. Conclusions There was no difference in the total Constant score between DHC and controls. However, pain was improved at 3 months after DHC. The differences found in subscores for pain should be explored in future studies. Trial registration clinicaltrials.gov Identifier: NCT 01022775.

Multi-needle aponeurotomy for advanced Dupuytren’s disease: Preliminary results of safety and efficacy (MNA 1 Study)

AIM To assess the safety and efficacy of multi-needle aponeurotomy (MNA) for advanced Duputrens disease. METHODS This prospective study included patients with age more than 17 years, Dupuytrens contracture with palmo-digital or poly-digital involvement, presumed NA number needed to treat>4, and availability for at least 1-month follow-up after MNA. Outcome measures were Tubiana score and passive extension deficit, after MNA and at 1 and 6 months; self-assessed disability and satisfaction at 1 and 6 months; and adverse events (AEs). RESULTS Thirty patients were included. MNA was performed on 37 hands and 99 rays. Among 25 assessed MNA sessions for treatment-related discomfort, patients considered 22 (88%) not at all to moderately painful. Six minor AEs, representing 2 for every 100 NAs, were reported. Tubiana scores at baseline (5.3±2.3, n=35) were improved after treatment (1.7±1.8, n=32, P<0.0001), at 1 month (2.2±1.4, n=26, P<0.0001) and at 6 months (2.8±2.7, n=19, P<0.01). Passive extension deficit was greatly reduced after treatment and persisted at follow-up. Disability scores at baseline (27.6±26.9, n=37) were reduced at 1 month (13.2±19.5, n=26, P=0.02) and at 6 months (5.2±11.6, n=20, P<0.001). Patients were highly satisfied at 1 month (100%, n=25) and 6 months (95%, n=19). CONCLUSION MNA appears safe and effective for advanced Dupuytrens disease. It could become a treatment of reference and contribute to reducing the need for surgery in this indication.

Efficacy of a functional restoration program for chronic low back pain: prospective 1-year study.

OBJECTIVE To evaluate the efficacy of a functional restoration program for patients with chronic low back pain, using overall disability and work ability as the primary evaluation criteria. PATIENTS AND METHODS We prospectively studied patients aged 18 years or older who had been on sick leave because of nonspecific low back pain for at least 3 months and whose job position was still open. The program was delivered on a day-hospital basis 5 days a week for 5 weeks. Patients were followed up for 1 year. RESULTS We included 39 patients, 11 females and 28 males with a mean (± SD) age of 43 ± 8 years and a mean sick-leave duration of 10 ± 7 months. After 1 year, 26 (67%) patients reported improvements and 25 (64%) had returned to work. Compared to the year before the program, the number of sick leave days was decreased by 51% (120 ± 140 vs. 244 ± 114, P < 0.05). The work-and-leisure-activities subscore of the validated French version of the Dallas Pain Questionnaire (DRAD) was significantly improved (57 ± 24 vs. 70 ± 17 at baseline, P < 0.05). The patients still on sick leave after 1 year were older and had greater alterations in baseline DRAD subscores for anxiety/depression and daily activities, compared to the patients who had returned to work. CONCLUSIONS Our functional restoration program was effective and allowed two-thirds of patients to resume work. Factors associated with failure to resume work were well-known correlates of chronicity. Our results support the use of functional restoration programs in patients with incapacitating low back pain. They suggest that functional restoration may deserve to be started earlier, after only 3 months with chronic pain, in patients who are unable to work.