R. Terracher

Rôle de la courbure rachidienne sagittale dans la survenue des luxations précoces après reprise de prothèse totale de hanche: À propos d’une analyse prospective de 49 reprises de prothèse totale

Resume La statique pelvienne et lombaire de 49 patients operes pour changement de prothese totale de hanche entre septembre 2000 et mars 2002 a fait l’objet d’une etude prospective. Cinq patients ont presente une luxation postoperatoire, malgre l’absence apparente de defaut de positionnement des implants. La valeur moyenne de la pente sacree etait significativement differente (p = 0,006) chez les patients s’etant luxes en comparaison avec ceux indemnes de luxation. Cette difference restait significative (p = 0,017) si on limitait l’etude aux 33 patients ne presentant aucun facteur de risque associe de luxation postoperatoire (antecedents de luxation recidivante, ou d’interventions multiples, ou infectieux, pseudarthrose du grand trochanter). Notre etude evoque le role de la statique pelvienne et lombaire dans la survenue de luxations postoperatoires apres reprise de prothese totale de hanche qui doit etre analysee une fois les causes classiques eliminees. Elle permet enfin, d’isoler des sujets a risque, chez qui des artifices techniques anti-luxation peuvent etre discutes.PURPOSE OF THE STUDY Hip dislocation after revision total hip arthroplasty (RTHA) is a frequent post-operative complication. Certain risk factors are well identified (nonunion of the greater trochanter, history of recurrent dislocation or infection, multiple procedures), the role of spine morphological remains to be fully examined. The purpose of this prospective analysis was to assess the role of spine morphology in post-operative dislocations. MATERIAL AND METHODS Forty-nine patients who underwent RTHA between September 2002 and March 2002 were evaluated prospectively. A complete pre- and postoperative spinal work-up was available for all patients to evaluate the lumbopelvic static using the Legaye and Duval Beaupère morphology criteria and the pelvic-femoral angle to assess hip joint extension. Pre-, per- and post-operative data including the usual risk factors for dislocation related to the clinical situation and the technique used were recorded on a digital datasheet. Five patients developed postoperative dislocation despite the absence of defective implant position. There was no relation with access (p=0.832) or pelvic-femoral angle (p=0.515). RESULTS The mean value of the sacral slope was significantly different (p=0.006) in patients who developed dislocation in comparison with the other patients. This difference remained significant (p=0.017) for the cohort of 33 patients who had no associated risk factor for postoperative dislocation (history of recurrent dislocation or infection, multiple procedures, tight nonunion of the greater trochanter). DISCUSSION Our results suggest that the morphology of the lumbar spine can be involved in the risk of postoperative dislocation. The morphology of the lumbar spine affects the pelvic static and thus the landmarks usually used for implantation, but it can also limit the amplitude of pelvic movement when changing from the sitting to the standing position, which would be compensated for by greater hip movement, particularly extension. The method we used did not fully take into account the consequences of changes in spinal balance due to thoracic deformations nor to analgesic (or not) hip flexion and subsequent deformation of the lumbar spine.

Painful patellofemoral instability secondary to peroperative patellar fracture during bone-patellar tendon-bone autograft harvesting for anterior cruciate ligament reconstruction.

Reconstructive surgery of the anterior cruciate ligament (ACL) of the knee in young active patients is a routine procedure, but with certain risks that need to be taken into account. Peroperative patellar fracture after bone-patellar tendon-bone autograft harvesting is a rare complication, which can significantly impair the functional outcome of ACL single-bundle reconstruction. We report the case of a patient presenting with disabling patellofemoral syndrome 3 years after arthroscopic ACL reconstruction by bone-tendon-bone autograft, revealing unnoticed mal-union of a iatrogenic sagittal patellar fracture. Patellar osteotomy corrected this painful iatrogenic patellar instability.

Sorveglianza di un paziente sotto gesso

La sorveglianza di un paziente sotto gesso e guidata dall’anamnesi e dall’esame clinico. La ricerca di complicazioni dalle conseguenze a volte gravi e indispensabile: l’intervallo tra la confezione del gesso e la visita consente di orientare questa ricerca. La prevenzione di queste complicazioni si basa in parte sull’informazione data al paziente e in parte sulla qualita della confezione del gesso, la cui tecnica non viene dettagliata in questo articolo. La conoscenza precisa dei segni clinici e l’ascolto del paziente consentono una diagnosi precoce che riduce i rischi di sequele.

Seguimiento del paciente enyesado

El seguimiento del paciente enyesado esta determinado por la anamnesis y la exploracion clinica. Es obligatoria la busqueda de complicaciones, cuyas consecuencias pueden ser graves. La demora entre la colocacion del yeso y la consulta permite orientar esa busqueda. La prevencion de las complicaciones se basa en parte en la informacion que se ofrece al paciente y en la calidad de la colocacion del yeso, cuya tecnica no se detallara en este articulo. El conocimiento preciso de sus signos clinicos y la escucha del paciente permiten un diagnostico precoz que reduce el riesgo de secuelas.

Vigilancia del paciente enyesado

La vigilancia de un paciente que tiene una escayola se basa en la anamnesis y la exploracion clinica. La busqueda de complicaciones a veces graves resulta imprescindible. El intervalo entre la confeccion de la ferula y la consulta permite orientar esta busqueda. La prevencion de las complicaciones depende, en parte, de la informacion aportada por el paciente y de la calidad de la confeccion de la ferula, cuya tecnica no se detallara en este articulo. El conocimiento preciso de los signos clinicos y la escucha atenta del paciente permitiran realizar un diagnostico precoz capaz de reducir el riesgo de secuelas.

Escoliosis del adulto

Existen dos grupos contrapuestos de escoliosis: las escoliosis como secuelas de la adolescencia, cuya degradacion acontece fundamentalmente en la primera mitad de la vida, y las escoliosis lumbares del adulto, que plantean problemas en la segunda mitad.