Nicolas Lefevre

Treatment of Pigmented Villonodular Synovitis of the Knee

PURPOSE We aimed to determine the rate of local recurrence, the rate of postoperative complications, and the functional outcome at final follow-up of surgical and nonsurgical treatment approaches for pigmented villonodular synovitis (PVNS) of the knee. METHODS Medline, Embase, and the Cochrane Library were systematically searched for studies that reported the results of treatment for any type of PVNS between January 1, 1950, and August 1, 2013. Two authors extracted the data independently using predefined data fields including study quality indicators. RESULTS Sixty studies (1,019 patients) met the inclusion criteria. Thirty-five presented data on the treatment of localized pigmented villonodular synovitis (LPVNS), 40 on diffuse pigmented villonodular synovitis (DPVNS), 1 on extra-articular LPVNS, and 7 on DPVNS with extra-articular involvement. Many therapeutic options were reported. Depending on these options, DPVNS recurred in 8% to 70% of the series and LPVNS recurred in 0% to 8% of the series. For LPVNS, the 2 most-reported options were open localized synovectomy and arthroscopic local synovectomy. Between these 2 courses of treatment, no difference was found in terms of local recurrence (8.7% for open synovectomy and 6.9% for arthroscopic synovectomy) and postoperative complications (<1% for open synovectomy and 0% for arthroscopic synovectomy). For DPVNS, the 2 most-reported options were open total synovectomy and arthroscopic total synovectomy. Between these 2 courses of treatment, no difference was found in terms of local recurrence (22.6% for open synovectomy and 16.1% for arthroscopic synovectomy). However, we found a lower rate of reported complications between open synovectomy (19.3%) and arthroscopic synovectomy (0%). Internal irradiation or external beam radiation as an adjuvant treatment to surgical synovectomy seemed to decrease the rate of local recurrence in DPVNS cases with a high risk of recurrence. Finally, we found a great heterogeneity in the way the functional results were reported, and no valid conclusion could be made based on the data we extracted. CONCLUSIONS We found no difference in local recurrence rates after open or arthroscopic surgery for either LPVNS or DPVNS. However, a lower rate of postoperative complications was reported after arthroscopic surgery for DPVNS. LEVEL OF EVIDENCE Level IV, systematic review of Level IV therapeutic studies.

Use of hydroxyurea in prevention of stroke in children with sickle cell disease

To the editor: We carefully read the paper by Zimmerman and colleagues[1][1] about the possible effect of hydroxyurea on the transcranial doppler flow velocities in children with sickle cell disease. We reviewed the transcranial dopplers (TCD) performed on the children with sickle cell disease in

Acute Postoperative Pain Management at Home After Ambulatory Surgery: A French Pilot Survey of General Practitioners’ Views

IMPLICATIONS We assessed the views of French general practitioners concerning pain relief at home after ambulatory surgery in a cross-sectional prospective survey. The results revealed that there is need for improvement, mainly in prescribing more suitable analgesic protocols and optimizing postdischarge relationships between physicians.

Dimensions of pure chronic fatigue: psychophysical, cognitive and biological correlates in the chronic fatigue syndrome

ObjectivesTo investigate associated dimensions of fatigue regarding cognitive impairment, psychomotor performances, muscular effort power and circulating cytokine levels and their relations to symptom intensity in a sample of pure chronic fatigue syndrome (CFS) patients without overlapping objective sleepiness or sleep disorders.Methods16 CFS patients were compared to 14 matched controls. We assessed structured symptom-scales, polysomnography, multiple sleep latency tests, attention (Zazzo-Cancellation ZCT, digit-symbol-substitution DSST), psychomotor vigilance and speed (PVT, finger tapping test, FTT), dynamometer handgrip force (tonic and phasic trials) and circulating cytokines (IFN-γ, IL-1b, IL-6, IL-8, IL-10, TNF-α).ResultsIn addition to fatigue, CFS patients presented with higher affective symptom intensity and worse perceived sleep quality. Polysomnography showed more slow-wave sleep and microarousals in CFS but similar sleep time, efficiency and light-sleep durations than controls. Patients presented with impaired attention (DSST, ZCT), slower reaction times (PVT) but not with lower hit rates (FTT). Notwithstanding lower grip strength during tonic and phasic trials, CFS also presented with higher fatigability during phasic trials. Cytokine levels were increased for IL-1b, IL-8, IL-10 and TNF-α and fatigue intensity was correlated to grip strength and IL-8.ConclusionsIn contrast to sleepiness, chronic fatigue is a more complex phenomenon that cannot be reduced to one single measured dimension (i.e., sleep propensity). Showing its relations to different measurements, our study reflects this multidimensionality, in a psychosomatic disorder such as CFS. To obtain objective information, routine assessments of fatigue should rule out sleepiness, combine aspects of mental and physical fatigue and focus on fatigability.

Return to Sport After Primary and Revision Anterior Cruciate Ligament Reconstruction A Prospective Comparative Study of 552 Patients From the FAST Cohort

Background: Few studies have reported the return-to-sport rate at 1-year follow-up after primary and revision anterior cruciate ligament (ACL) reconstruction. Purpose: To compare the return-to-sport rate 1 year after primary and revision ACL reconstruction in the same cohort according to 2 modalities: any kind of sport and the patient’s usual sport at the same level as before the injury. Study Design: Cohort study; Level of evidence, 3. Methods: A single-center, prospective cohort study of patients undergoing ACL reconstruction (French prospective Acl STudy [FAST]) was begun in 2012. A comparative study was performed based on a retrospective analysis of data collected prospectively. Included were all athletes aged 18 to 50 years who underwent primary or revision isolated ACL reconstruction between 2012 and 2014. Two groups were formed: primary reconstruction and revision reconstruction. The main criterion was return to sport at 1-year follow-up (yes/no); secondary criteria were return to the usual sport at 1-year follow-up, knee function (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS] scores), and psychological readiness (ACL–Return to Sports after Injury [ACL-RSI] score) at 6 months and 1 year. Results: A total of 552 patients (primary reconstruction group: n = 497, revision reconstruction group: n = 55) were included in the study. There were 373 men and 179 women (mean [±SD] age, 30.2 ± 8.4 years). No significant difference in the return-to-sport rate was found between the 2 groups at 1-year follow-up (primary reconstruction group: 90.9%, revision reconstruction group: 87.3%; P = .38), but patients in the primary reconstruction group resumed their usual sport significantly more often (primary reconstruction group: 63.6%, revision reconstruction group: 49.1%; P = .04). Eight (1.4%) retears occurred during a new sport-related injury within a mean 8.9 ± 2.9 months: 7 (1.4%) in the primary reconstruction group and 1 (1.8%) in the revision reconstruction group (P = .8). At 1-year follow-up, functional scores were significantly better in the primary reconstruction group for subjective IKDC (82.6 ± 13.3 vs 78.4 ± 16.6; P = .04); KOOS Symptoms/Stiffness (73.3 ± 15.2 vs 67.7 ± 19.6; P = .02), Activities of Daily Living (96.3 ± 6.4 vs 94.3 ± 9.1; P = .04), Sport (79.7 ± 19.1 vs 69.1 ± 24.8; P = .0004), and Quality of Life (69.6 ± 22.7 vs 54.7 ± 24.8; P < .00001) subscales; and ACL-RSI (65 ± 23 vs 49.5 ± 24.8; P < .00001). On multivariate analysis, patients who were more likely to resume their usual sport at 1 year were high-level players (odds ratio [OR], 2.2) who underwent primary reconstruction (OR, 2.0) and had better KOOS Quality of Life (OR, 1.7) and subjective IKDC (OR, 2.1) scores at 6-month follow-up without complications or retears during the first postoperative year (OR, 2.6). Conclusion: At 1-year follow-up, there was no significant difference in the return-to-sport rate between primary and revision ACL reconstruction. Patients who underwent primary reconstruction returned to their usual sport significantly more often. Trial Registration: NCT02511158 (ClinicalTrials.gov identifier).

Return to Sport After Rotator Cuff Tear Repair A Systematic Review and Meta-analysis

Background: One of the most frequent demands from athletes after rotator cuff tear repair is to return to sport, if possible at the same level of play. Purpose: The main goal of this study was to determine the rate of return to sport after treatment of rotator cuff tears. Study Design: Meta-analysis and systematic review. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review and meta-analysis of the results in the literature, as well as for the presentation of results. A search of the literature was performed on the electronic databases MEDLINE, Scopus, EMBASE, and the Cochrane Library. The quality of the included studies was evaluated according to the MINORS (Methodological Index for Nonrandomized Studies) checklist. Inclusion criteria were studies in English evaluating return to sport after treatment of traumatic, degenerative, partial or full-thickness rotator cuff tears in patients practicing a sport regularly, whatever the level, all ages and sports included. The main judgment criterion was the number of patients who returned to a sports activity after treatment of a rotator cuff tear. The criterion was analyzed in 2 ways: return to sport (yes/no) and the level of play (identical or higher/lower level). Results: Twenty-five studies were reviewed, including 859 patients (683 athletes), all treated surgically after a mean follow-up of 3.4 years (range, 0.3-13.4 years). The level of sports was recorded in 23 studies or 635 (93%) athletes and included 286 competitive or professional athletes and 349 recreational athletes. The most commonly practiced sports were baseball (224 participants), tennis (104 participants), and golf (54 participants). The overall rate of return to sport was 84.7% (95% CI, 77.6%-89.8%), including 65.9% (95% CI, 54.9%-75.4%) at an equivalent level of play, after 4 to 17 months. Of the professional and competitive athletes, 49.9% (95% CI, 35.3-64.6%) returned to the same level of play. Conclusion: Most recreational athletes return to sports at the same level of play as before their injury, but only half of professional and competitive athletes return to an equivalent level of play.

Sex and inflammation in respiratory diseases: a clinical viewpoint

This review discusses sex differences in the prognosis of acute or chronic inflammatory diseases. The consequences of severe inflammation vary in relation to sex, depending on illness duration. In the majority of acute diseases, males present higher mortality rates, whereas continuous chronic inflammation associated with tissue damage is more deleterious in females. The recruitment of cells, along with its clinical expression, is more significant in females, as reflected by higher inflammatory markers. Given that estrogens or androgens are known to modulate inflammation, their different levels in males and females cannot account for the sexual dimorphism observed in humans and animals from birth to death with regard to inflammation. Numerous studies evaluated receptors, cytokine production, and clinical outcomes in both animals and humans, revealing that estrogens clearly modulate the immune response, but the results are contradictory and difficult to link to hormone concentrations. Even in prepubescent children, the presentation of acute pneumonia or chronic diseases mimics the adult pattern. Several genes located on the X chromosome have been shown to encode molecules involved in inflammation. Moreover, 10% to 15% of the genes from silenced X chromosome may escape inhibition. Females are also a mosaic of cells with genes from either paternal or maternal X chromosome. Therefore, polymorphism of X-linked genes would result in the presence of two cell populations with distinct regulatory arsenals, providing females with greater diversity to fight against infectious challenges, in comparison with the uniform cell populations in hemizygous males. The similarities observed between males and Turner syndrome patients using an endotoxin stimulation model support the difference in gene expression between monosomy and disomy for the X chromosome. Considering the enhanced inflammation in females, cytokine production may be assumed to be higher in females than males. Even if all results are not clear-cut, nonetheless, many studies have reported higher cytokine levels in both male humans and animals than in females. High IL-6 levels in males correlated with poorer prognosis and shorter longevity. A sound understanding of the basic regulatory mechanisms responsible for these gender differences may lead to new therapeutic targets.

SEX DIFFERENCES IN INFLAMMATORY CYTOKINES AND CD99 EXPRESSION FOLLOWING IN VITRO LIPOPOLYSACCHARIDE STIMULATION

ABSTRACT Sex influences the severity and evolution of various inflammatory conditions. Although many studies have demonstrated the role of sex hormones in immune response modulation, recent clinical data revealed significant sex differences in inflammatory markers in prepubertal children, suggesting a genetic contribution. We studied several immune functions depending on X-linked genes in healthy adults of both sexes: the respiratory burst of purified neutrophils, the CD99 and CD11b expression of stimulated leukocytes as markers of adhesion and diapedesis, and the production of inflammatory cytokines in whole blood after incubation with lipopolysaccharide for 24 h. The percentage of monocytes expressing CD99 was higher in men than in women, thus confirming the higher CD99 expression reported in males using reverse transcription–polymerase chain reaction. In addition, we observed a higher tumor necrosis factor &agr; and tendency toward higher interleukin (IL) 6 production in men after lipopolysaccharide stimulation. These differences may contribute to the higher mortality reported in men with septic shock. Tumor necrosis factor &agr; production significantly correlated with monocyte count, with men having a higher monocyte count than women. When cytokine levels were normalized to monocyte counts, a higher IL-8 production was found in women, which may explain the higher neutrophil count observed in girls with acute inflammatory diseases, because IL-8 is a major neutrophil chemoattractant. These sex differences regarding the activation of certain X-linked genes involved in innate immunity confirm our clinical observations, thus supporting the role of sex chromosomes in inflammatory response.

Gender differences and inflammation: an in vitro model of blood cells stimulation in prepubescent children

BackgroundGender influences clinical presentations and markers in inflammatory diseases. In many chronic conditions, frequency of complications is greater in females, suggesting that continuous inflammatory reaction may induce greater damage in targeted organs and functions.MethodsTo investigate gender dimorphism at a cellular level, we evaluated the production of cytokines implicated in inflammatory processes (IL -1, IL- 6, PGE-2 and TNF alpha), in healthy prepubescent children of both sex and Turners syndrome (TS) patients (genotype XO). We used stimulation by LPS (0.2 and 1 ng/ml) and Pokeweed Mitogen (PWM) on overnight cultures from whole blood samples, collected in 57 subjects: 22 girls/26 boys (5-96 months), and 9 TS patients (6-15 years). The primary outcome was to evaluate if gender influences the production of cytokines, with potential relation to X chromosome monosomy. Secondary endpoints were to relate different cytokines level productions and conditions.ResultsWe confirm the male over female increased cytokine productions already observed in adults. This is contrasting with numerous observations obtained in vivo about increased production of inflammatory markers in females (CRP, ESR and neutrophil counts), as we recently reported in children. Relative variations of the dimorphism according to stimulus, its concentration and cytokine type are discussed, presenting IL6 with a modulating function that could be more potent in males. TS subjects follow mostly the male pattern of reactivity, sustaining the role of some gene expression differing with X chromosome monosomy and disomy.ConclusionsPersistence of the latter dimorphism throughout life casts doubts on its direct relationship with individual hormonal status, as already documented by others in vitro, and supports the need for alternative hypothesis, such as the influence of X chromosome gene products escaping X inactivation in females and absent in subjects with X monosomy (males, TS).

Outpatient surgery feasibility in anterior cruciate ligament reconstruction: a prospective comparative assessment.

INTRODUCTION The main objective of this study was to assess the feasibility of outpatient surgery in anterior cruciate ligament (ACL) reconstruction. We hypothesized that if the patient underwent the procedure within a dedicated organization, safety would be ensured. PATIENTS AND METHODS A non-randomized, prospective, comparative, single-operator study conducted in 2012-2013 included all patients undergoing first-line surgery for ACL arthroscopic reconstruction using a short hamstring graft. The outpatient group (OP) included patients who were eligible for outpatient surgery and provided consent; the conventional hospitalization group (CH) comprised those patients not suitable for outpatient surgery and those who refused it. The main evaluation criterion was failure of the admission modality defined as hospitalization of a patient who had undergone outpatient surgery or rehospitalization in the first week after discharge. The secondary evaluation criteria were the rate of postoperative complications, postoperative pain, use of analgesics, and patient satisfaction. A total of 138 patients were included: 71 in the OP group and 67 in the CH group, with a mean age of 29.6±9 years. Twenty-nine percent of the patients refused outpatient surgery. In the CH group, the mean hospital stay lasted 2.7±0.8 days. RESULTS One patient in the OP group was hospitalized with localized bleeding and there were no rehospitalizations. Six early postoperative complications were noted in each group. The mean postoperative pain on D0-D4 and patient satisfaction were similar in the two groups. CONCLUSION This prospective study encountered no serious events after outpatient ACL reconstruction surgery. In a selected population, the risks are comparable to those in conventional hospitalization. LEVEL OF EVIDENCE Level III, comparative study.