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Las osteonecrosis epifisarias no traumaticas del adulto se relacionan con tres causas esenciales: la administracion de corticoides, la intoxicacion etilica y la anemia drepanocitica. Ademas de estas tres causas principales, hay muchas otras, como los trastornos del metabolismo lipidico, que tambien pueden causar necrosis epifisarias. Estas afectan sobre todo a la articulacion de la cadera. Algunas pueden producir osteonecrosis multifocales que entonces afectan preferentemente al hombro y la rodilla, despues de la cadera. Es raro observar otras zonas afectadas, salvo en el caso de algunas causas que producen afecciones de zonas especificas (como la columna en la anemia drepanocitica). El diagnostico en la fase precoz se basa esencialmente en la resonancia magnetica (RM) que, en la mayoria de los casos, permite establecer un diagnostico de certeza de la enfermedad. Las modalidades terapeuticas de las osteonecrosis epifisarias dependen fundamentalmente de la fase diagnostica. Se puede hacer un tratamiento conservador de la articulacion si el diagnostico se ha establecido precozmente, en particular mediante una RM.

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and, optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electromagnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the hip, including osteonecrosis (aseptic necrosis) involving bone marrow, bone, and cartilage, and chondral injuries involving articular cartilage, synovium, and bone marrow. Promising and established treatment modalities for osteonecrosis include nonweightbearing; pharmacological treatments including low molecular-weight heparin, prostacyclin, statins, bisphosphonates, and denosumab, a receptor activator of nuclear factor-kB ligand inhibitor; extracorporeal shock wave therapy; pulsed electromagnetic fields; core decompression surgery; cellular therapies including bone marrow aspirate comprising mesenchymal stromal cells (MSCs aka mesenchymal stem cells) and bone marrow autologous concentrate, with or without expanded or cultured cells, and possible addition of bone morphogenetic protein-2, vascular endothelial growth factor, and basic fibroblast growth factor; and arterial perfusion of MSCs that may be combined with addition of carriers or scaffolds including autologous MSCs cultured with beta-tricalcium phosphate ceramics associated with a free vascularized fibula. Promising and established treatment modalities for chondral lesions include autologous platelet-rich plasma; hyaluronic acid; MSCs (in expanded or nonexpanded form) derived from bone marrow or other sources such as fat, placenta, umbilical cord blood, synovial membrane, and cartilage; microfracture or microfracture augmented with membrane containing MSCs, collagen, HA, or synthetic polymer; mosaicplasty; 1-stage autologous cartilage translation (ACT) or 2-stage ACT using 3-dimensional spheroids; and autologous cartilage grafting; chondral flap repair, or flap fixation with fibrin glue. Hip pain is catastrophic in young patients, and promising therapies offer an alternative to premature arthroplasty. This may address both physical and psychological components of pain; the goal is to avoid or postpone an artificial joint. Level of Evidence Level V, expert opinion.

This study compared the clinical and radiological results of bone marrow mesenchymal stem cell implantation with traditional simple core decompression (CD) using a matched pair case-control design for osteonecrosis of the humeral head (ONHH) after fracture of the proximal humerus.We retrospectively reviewed 64 patients who had surgery for ONHH. Thirty patients had been treated with cell therapy between 2010 and October 2015, with 18 patients at pre-collapse stage (8 stages-I, 10 stages-II), and 12 patients at post-collapse stages (7 stages-III and 5 stages-IV). Using a matched pair case-control design, these 30 study patients were compared to 34 other patients who were treated with simple core decompression (CD) without cells (control group).The cell therapy group was treated with percutaneous mesenchymal cell (MSCs) injection obtained from bone marrow (BM) concentration. During a mean follow-up duration of 7years (5 to 10years), radiographs performed each year were used to evaluate the radiological results; the Constant score and visual analogue scale were chosen to assess the clinical results. We assessed stage progression, collapse and arthroplasty conversion rate. Survivor rate analysis was performed using these parameters as the primary endpoints.Among the 30 shoulders included in the cell therapy group, three (10%) humeral heads had collapsed at the most recent follow-up, versus 25 (74%) in 34 shoulders after simple core decompression (P0.0001). As consequence, we observed statistically significant difference (P=0.0001) in the humeral head survival (absence of arthroplasty conversion) rate at the end time point between the cell therapy group (93% survival) and simple core decompression (26% survival). Better results were obtained for early stages (stages I and II) osteonecrosis without collapse at baseline.Core decompression with cell therapy was a safe and effective procedure for treatment in the pre-collapse stages of posttraumatic shoulder osteonecrosis and improved the outcome of the disease as compared with simple core decompression without cells.

Artículo con numerosos autores, sólo se recogen el primero y los pertenecientes a la UAM, Background and study aim: Advanced therapy medicinal products (ATMP) frequently lack of clinical data on efficacy to substantiate a future clinical use. This study aims to evaluate the efficacy to heal long bone delayed unions and non-unions, as secondary objective of the EudraCT 2011-005441-13 clinical trial, through clinical and radiological bone consolidation at 3, 6 and 12 months of follow-up, with subgroup analysis of affected bone, gender, tobacco use, and time since the original fracture. Patients and methods: Twenty-eight patients were recruited and surgically treated with autologous bone marrow derived mesenchymal stromal cells expanded under Good Manufacturing Practices, combined to bioceramics in the surgical room before implantation. Mean age was 39 ±13 years, 57% were males, and mean Body Mass Index 27 ±7. Thirteen (46%) were active smokers. There were 11 femoral, 4 humeral, and 13 tibial non-unions. Initial fracture occurred at a mean ±SD of 27.9 ±31.2 months before recruit- ment. Efficacy results were expressed by clinical consolidation (no or mild pain if values under 30 in VAS scale), and by radiological consolidation with a REBORNE score over 11/16 points (value of or above 0.6875). Means were statistically compared and mixed models for repeated measurements estimated the mean and confidence intervals (95%) of the REBORNE Bone Healing scale. Clinical and radiological con- solidation were analyzed in the subgroups with Spearman correlation tests (adjusted by Bonferroni). Results: Clinical consolidation was earlier confirmed, while radiological consolidation at 3 months was 25.0% (7/28 cases), at 6 months 67.8% (19/28 cases), and at 12 months, 92.8% (26/28 cases including the drop-out extrapolation of two failures). Bone biopsies confirmed bone formation surrounding the bioce- ramic granules. All locations showed similar consolidation, although this was delayed in tibial non-unions. No significant gender difference was found in 12-month consolidation (95% confidence). Higher consoli- dation scale values were seen in non-smoking patients at 6 ( p = 0.012, t -test) and 12 months ( p = 0.011, t -test). Longer time elapsed after the initial fracture did not preclude the occurrence of consolidation. Conclusion: Bone consolidation was efficaciously obtained with the studied expanded hBM-MSCs com- bined to biomaterials, by clinical and radiological evaluation, and confirmed by bone biopsies, with lower consolidation scores in smokers, This research received funding from the European Union’s Sev- enth Framework Programme ( FP7/FP7-HEALTH-2009 ) with the RE- BORNE Project (under G.A. 241876), and the European Union’s Horizon 2020 Programme ( H2020-SC1 2016-2017 ), with the OR- THOUNION Project (under G.A. 7333288)

Background The Association Research Circulation Osseous (ARCO) presents the 2019 revised staging system of osteonecrosis of the femoral head (ONFH) based on the 1994 ARCO classification. Methods In October 2018, ARCO established a task force to revise the staging system of ONFH. The task force involved 29 experts who used a web-based survey for international collaboration. Content validity ratios for each answer were calculated to identify the levels of agreement. For the rating queries, a consensus was defined when more than 70% of the panel members scored a 4 or 5 rating on a 5-point scale. Results Response rates were 93.1%-100%, and through the 4-round Delphi study, the 1994 ARCO classification for ONFH was successfully revised. The final consensus resulted in the following 4-staged system: stage I—X-ray is normal, but either magnetic resonance imaging or bone scan is positive; stage II—X-ray is abnormal (subtle signs of osteosclerosis, focal osteoporosis, or cystic change in the femoral head) but without any evidence of subchondral fracture, fracture in the necrotic portion, or flattening of the femoral head; stage III—fracture in the subchondral or necrotic zone as seen on X-ray or computed tomography scans. This stage is further divided into stage IIIA (early, femoral head depression ≤2 mm) and stage IIIB (late, femoral head depression >2 mm); and stage IV—X-ray evidence of osteoarthritis with accompanying joint space narrowing, acetabular changes, and/or joint destruction. This revised staging system does not incorporate the previous subclassification or quantitation parameters, but the panels agreed on the future development of a separate grading system for predicting disease progression. Conclusion A staging system has been developed to revise the 1994 ARCO classification for ONFH by an expert panel-based Delphi survey. ARCO approved and recommends this revised system as a universal staging of ONFH.

Osteonecrosis of the femoral head (ONFH) is a common and refractory disease in orthopaedic clinics. The number of patients with ONFH is increasing worldwide every year. There are an estimated 8.12 million patients with nontraumatic osteonecrosis in China alone. Treatment of nontraumatic osteonecrosis has always been a clinical challenge for orthopaedic surgeons. To further standardize diagnosis and treatment of ONFH, these guidelines provide not only basic diagnosis, treatment, and evaluation systems for ONFH but also expert advice and standards in many aspects, including epidemiology, aetiology, diagnostic criteria, pathological staging, prevention and treatment options, and postoperative rehabilitation. The aetiological factors of ONFH can currently be divided into two major categories: traumatic and nontraumatic; however, the specific pathological mechanism of ONFH is not completely clear. Currently, the staging system of ONFH formulated by the Association Research Circulation Osseous is widely used in clinical practice. Based on the changes in the intraosseous blood supply at different stages, the corresponding nonsurgical and surgical treatments are recommended, and when there are risk factors for possible ONFH, certain preventive measures to avoid the occurrence of osteonecrosis are recommended. These guidelines provide brief classification criteria and treatment regimen for osteonecrosis. Specification of the aetiology, treatment plan based on comprehensive consideration of the different stages of osteonecrosis, hip function, age, and occupation of the patients are important steps in diagnosis and developing treatment strategies. Translational potential of this article: New advances in the epidemiology, etiology, pathophysiology, imaging, diagnosis and treatment of ONFH have been renewed in this revision. This guideline can be used for reference by orthopedic professionals and researchers, and for standardized diagnosis and treatment management under the clinical guidance, which is conducive to the prevention, treatment and further research of ONFH, improving the diagnosis and treatment level, making patients' symptoms under good control, and improving their quality of life. Keywords: Diagnosis, Guideline, Osteonecrosis of the femoral head (ONFH), Treatment

Background: The acetabular cup (AC) implant primary stability is an important determinant for the success of cementless hip surgery but it remains difficult to assess the AC implant fixation in the clinic. A method based on the analysis of the impact produced by an instrumented hammer on the ancillary has been developed by our group (Michel et al., 2016a). However, the soft tissue thickness present around the acetabulum may affect the impact response, which may hamper the robustness of the method. The aim of this study is to evaluate the influence of the soft tissue thickness (STT) on the acetabular cup implant primary fixation evaluation using impact analyses. Methods: To do so, different AC implants were inserted in five bovine bone samples. For each sample, different stability conditions were obtained by changing the cavity diameter. For each configuration, the AC implant was impacted 25 times with 10 and 30 mm of soft tissues positioned underneath the sample. The averaged indicator Im was determined based on the amplitude of the signal for each configuration and each STT and the pull-out force was measured. Findings: The results show that the resonance frequency of the system increases when the value of the soft tissue thickness decreases. Moreover, an ANOVA analysis shows that there was no significant effect of the value of soft tissue thickness on the values of the indicator Im (F = 2.33; p-value = 0.13). Interpretation: This study shows that soft tissue thickness does not appear to alter the prediction of the acetabular cup implant primary fixation obtained using the impact analysis approach, opening the path towards future clinical trials.

RESUME Chaque annee, environ 140 000 patients subissent une arthroplastie totale de la hanche (THA). Ceci est considere comme une intervention medicale sure et efficace pour restaurer la fonctionnalite de la hanche et retrouver une mobilite indolore chez les patients souffrant d’arthrose. Le nombre de personnes operees ou devant etre reoperees devrait augmenter en raison du vieillissement de la population et de la diminution de l’âge moyen a la premiere operation. Les protheses de hanche sont des produits d’ingenierie biomedicale innovants et de haute qualite. Alors qu’ils sont normalement concus pour durer 20 ans ou plus, leur duree de vie peut etre limitee par l’usure, ou d’autres complications. Le resultat clinique a long terme de la prothese depend de facteurs lies au type de prothese, de l’etat de sante du patient et de ses activites physiques postoperatoires, et depend egalement de l’expertise et de la pratique du chirurgien. Il est probable que le cout societal croissant des maladies musculo-squelettiques ne pourra etre gere que par une technologie medicale amelioree mais aussi compte tenu de la demande croissante par des mesures adequates qui devraient etre prises pour reduire la demande de chirurgie de revision.

Resume Introduction La gonarthrose etant dans la grande majorite des cas monocompartimentale, les osteotomies de reaxation du membre representent une solution logique pour limiter la degradation du compartiment arthrosique et retarder ainsi la mise en place d’une prothese. Les sujets jeunes ont une demande fonctionnelle importante. L’objectif de cette etude etait d’evaluer la reprise du sport et la qualite de vie apres osteotomie tibiale de valgisation (OTV) a un an chez les patients sportifs de moins de 60 ans. L’hypothese de notre etude etait que les patients reprennent leurs activites sportives a 1 an d’une OTV. Materiels et methodes Dans cette etude retrospective monocentrique entre janvier 2014 et aout 2015, 30 OTV chez des patients sportifs âges de moins de 60 ans, sans antecedent traumatique ou chirurgical, ont ete incluses. Le critere de jugement principal etait le taux de reprise du sport a un an selon le score de Tegner ; les criteres secondaires etaient les scores fonctionnels IKDC subjectif, Lysholm et SF-36. Resultats Le recul moyen etait de 1,3 ans [1–1,5] sans perdus de vue. Tous les patients ont repris une activite sportive a un an. Au total, 73,3 % ont repris leur activite sportive a un niveau egal a celui correspondant au debut des symptomes douloureux et 23,3 % a un niveau superieur. Il existait une amelioration significative de la qualite de vie evaluee par le score SF-36, de 65,3 % en preoperatoire a 72,5 % en postoperatoire (p = 0,01). Les donnees des patients en pre et postoperatoire a un an etaient comparables en termes de scores de Tegner (p = 0,167), IKDC (p = 0,093) et de Lysholm (p = 0,061). Conclusion L’OTV permet une reprise d’activite sportive a un an et une amelioration significative de la qualite de vie. Niveau de preuve Etude retrospective de cohorte niveau IV.

Resume Introduction Les osteotomies sont une solution logique pour retarder la degradation du compartiment arthrosique en modifiant les contraintes et eviter la mise en place de protheses chez le sujet jeune. L’osteotomie femorale de varisation (OFV) n’est recommandee que pour des deformations femorales en valgus superieures a 10°. L’objectif de cette etude etait d’evaluer l’interet de l’osteotomie tibiale de varisation (OTVar) chez des patients presentant une gonarthrose femoro-tibiale laterale sur genuvalgum inferieur a 10°. L’hypothese etait que l’OTVar permet d’obtenir un resultat satisfaisant et durable dans la gonarthrose femoro-tibiale laterale. Materiels et methode Dans cette etude retrospective, monocentrique continue. Dix-neuf OTVar d’âge moyen 54,5 ans ont ete inclus entre janvier 2005 et mai 2012. Les scores cliniques IKS genou et fonction et les mesures radiologiques ont ete calcules en preoperatoire, a 6 mois, 1 an et au dernier recul. Le critere de jugement principal etait clinique sur le score IKS Global. Un score inferieur a 140 ou la mise en place d’une prothese totale du genou etaient consideres comme des echecs. Les criteres de jugement secondaires etaient un angle HKA postoperatoire entre 180–183° et un interligne oblique de moins de 10°. Resultats Au recul moyen de 4,3 ans (2–9 ans). Dix patients avaient un score IKS p p Conclusion L’OTVar donne des resultats cliniques mediocres a moyen terme avec un taux d’echecs global de 52 %. Actuellement, l’OTVar ne trouve pas sa place dans la prise en charge chirurgicale de la gonarthrose femoro-tibiale laterale de moins de 10°. Niveau de preuve Etude retrospective de cohorte niveau IV.

In order to induce an efficient bone formation with human bone marrow mesenchymal stromal cells (hBMSC) associated to a scaffold, it is crucial to determine the key points of the hBMSC action after in vivo transplantation as well as the appropriate features of a scaffold. To this aim we compared the hBMSC behavior when grafted onto two biomaterials allowing different bone potential in vivo. The cancellous devitalized Tutoplast®-processed bone (TPB) and the synthetic hydroxyapatite/β-tricalcium-phosphate (HA/βTCP) which give at 6weeks 100% and 50% of bone formation respectively. We first showed that hBMSC adhesion is two times favored on TPB in vitro and in vivo compared to HA/βTCP. Biomaterial structure analysis indicated that the better cell adhesion on TPB is associated to its higher and smooth open pore architecture as well as its content in collagen. Our 6week time course analysis, showed using qPCR that only adherent cells are able to survive in vivo giving thus an advantage in term of cell number on TPB during the first 4weeks after graft. We then showed that grafted hBMSC survival is crucial as cells participate directly to bone formation and play a paracrine action via the secretion of hIGF1 and hRANKL which are known to regulate the bone formation and resorption pathways respectively. Altogether our results point out the importance of developing a smooth and open pore scaffold to optimize hBMSC adhesion and ensure cell survival in vivo as it is a prerequisite to potentiate their direct and paracrine functions.Around 10% of skeletal fractures do not heal correctly causing nonunion. An approach involving mesenchymal stromal cells (MSC) associated with biomaterials emerges as an innovative strategy for bone repair. The diversity of scaffolds is a source of heterogeneity for bone formation efficiency. In order to better determine the characteristics of a powerful scaffold it is crucial to understand their relationship with cells after graft. Our results highlight that a biomaterial architecture similar to cancellous bone is important to promote MSC adhesion and ensure cell survival in vivo. Additionally, we demonstrated that the grafted MSC play a direct role coupled to a paracrine effect to enhance bone formation and that both of those roles are governed by the used scaffold.

Summary Autogenous bone graft (autograft) remains the gold standard in the treatment of many orthopedic problems. However, graft harvest can lead to perioperative morbidity and increased cost. We tested the hypothesis that an osteoconductive matrix, beta-tricalcium phosphate (β-TCP), would be a safe and effective alternative to autograft alone. Beta-tricalcium phosphate (β-TCP) is considered as one of the most promising biomaterials for bone reconstruction. This study analyzes the outcomes of patients who received β-TCP as bone substitutes in orthopedic surgery. Methods A total of 50 patients were enrolled in a controlled, non-inferiority clinical trial to compare the safety and efficacy of β-TCP (25 patients) with those of autograft (25 patients) in indications requiring usually autograft. These 50 patients were categorized according to the etiology and morphology of the 54 bone defects resulting from elective surgical procedures, such as 34 open-wedge high tibial osteotomies, and 20 osteonecrosis treatments with core decompression. Radiographic (healing process with or without integration of β-TCP), clinical (no other surgical procedure), functional outcomes and safety (with or without complications) were assessed through fifty-two weeks postoperatively. Results With regard to the primary endpoint (radiographic evolution), the fusion rate of the 34 open-wedge osteotomies was 100% (17 among 17) for patients in the group with β-TCP compared with 94% (16 among 17) for patients in the autograft group. For the 20 cavitary defects (osteonecrosis), the radiographic union rates, as determined by the presence of osseous bridging, were 100% for patients in the group with β-TCP and 100% for those in the autograft group. Clinically at one year, all quality-of-life and functional outcome data supported non-inferiority of β-TCP compared with autograft, and patients in the β-TCP group were found to have less pain and an improved safety profile. Conclusions Treatment with β-TCP resulted in comparable fusion rates, less pain and fewer side effects as compared with treatment with autograft. This study established clinical parameters where the β-TCP alone can successfully support the osteogenic process.

Resume Objectif Le but de cette etude a ete d’evaluer l’interet de l’echo-guidage (EG) pour la realisation des ponctions vasculaires dans la pratique de therapies endovasculaires. L’evaluation s’est faite par analyse du taux d’echecs et de complications des acces vasculaires percutanes avec et sans echo-guidage. Materiels et methodes Nous avons revu et analyse toutes les revascularisations percutanees consecutives depuis le debut de l’utilisation de systemes de fermeture arterielle en 2008. L’EG a commence en novembre 2011. Les criteres principaux evalues entre les groupes avec echo-guidage (EG+) et sans echo-guidage (EG−) etaient les taux d’echec de ponction et les taux de complications (hematome necessitant transfusion ou hemostase, faux anevrisme, dissection, thrombose, infection). Resultats Entre 2008 et 2014, 841 ponctions ont ete realisees par voie femorale (85 %), voie humerale (12 %), voie poplitee (1 %), voie axillaire (0,5 %), voie tibiale posterieure (0,5 %) avec des introducteurs de 4F a 12F. Nous avons observe 20 complications (2,3 %) : 6 hematomes, 4 pseudoanevrismes, 3 thromboses, une paralysie nerveuse, une infection de stent et 7 echecs percutanes. Les complications et les echecs etaient significativement moins frequents quand l’echographe etait utilise (0,9 % contre 3 %, p = 0,02 ; 0,2 % contre 1,8 %, p = 0,01). Conclusion L’echo-guidage permet de diminuer significativement le taux de complications et d’echecs des acces percutanes. Cet outil peut permettre d’envisager une augmentation des angioplasties percutanees en hospitalisation ambulatoire.

Resume Objectifs La prevalence de l’anevrisme de l’aorte abdominale (AAA) est comprise, entre 4,1 % et 8,9 %. Le risque de rupture est lie a l’evolution de son diametre. Le role du syndrome d’apnee du sommeil (SAS) reste discute. Les objectifs etaient de comparer la prevalence du SAS chez les patients porteurs d’un AAA avec celle de la population generale et d’un lien entre le diametre de l’AAA et la severite du SAS. Methode Entre juin 2012 et decembre 2014, tous les patients adresses pour AAA ont ete inclus. Un angioscanner et une polysomnographie ont ete realises. Un IAH > 10 a ete choisi comme critere de SAS. La prevalence de SAS a ete comparee a celle de la population generale. Les patients ont ete repartis en deux groupes : groupe 1 (pas de SAS et SAS leger) ; groupe 2 (SAS modere et severe). Resultats Cinquante-deux patients ont ete inclus. Cinquante-six pour cent des patients presentaient un SAS. Cette prevalence etait significativement plus elevee que celle de la population generale (56 % vs 8 %, p Conclusion La frequence du syndrome d’apnee du sommeil apparait etre plus elevee chez les patients porteurs d’un AAA. Le diametre de l’anevrisme et la severite du SAS semblent etre correles.

Background Glucocorticoid usage, a leading cause of osteonecrosis of the femoral head (ONFH), and its prevalence was reported in 25%-50% of non-traumatic ONFH patients. Nevertheless, there have been no unified criteria to classify glucocorticoid-associated ONFH (GA-ONFH). In 2015, the Association Research Circulation Osseous addressed the issue of developing a classification scheme. Methods In June 2017, a task force was set up to conduct a Delphi survey concerning ONFH. The task force invited 28 experts in osteonecrosis/bone circulation from 8 countries. Each round of the Delphi survey consists of questionnaires, analysis of replies, and feedback reports to the panel. After 3 rounds of the survey, the panel reached a consensus on the classification criteria. The response rates were 100% (Round 1), 96% (Round 2), and 100% (Round 3), respectively. Results The consensus on the classification criteria of GA-ONFH included the following: (1) patients should have a history of glucocorticoid use >2 g of prednisolone or its equivalent within a 3-month period; (2) osteonecrosis should be diagnosed within 2 years after glucocorticoid usage, and (3) patients should not have other risk factor(s) besides glucocorticoids. Conclusion Association Research Circulation Osseous established classification criteria to standardize clinical studies concerning GA-ONFH.

Resume Un homme de 73 ans, insuffisant respiratoire chronique, est admis en urgence dans l’unite de soins intensifs pneumologie pour hemoptysie et hypoxemie majeures. Il presentait une defaillance respiratoire aigue avec hypertension arterielle pulmonaire. Le saignement provenait de la bronche lobaire inferieure gauche. A ce niveau, existaient deux formations nodulaires et une petite fistule arterioveineuse avec shunt. L’embolisation arterielle pulmonaire etait recusee du fait d’une arteriopathie diffuse majeure. Une lobectomie inferieure gauche etait realisee. La veine pulmonaire superieure gauche s’abouchait dans le tronc veineux innomine constituant un retour veineux pulmonaire anormal partiel. Cette anomalie etait corrigee. Les suites operatoires etaient simples. On notait une correction du shunt vasculaire et une amelioration de la surcharge des cavites cardiaques droites. Le patient controle a un an se portait bien, avec une fonction cardiaque amelioree sans recidive de l’hemoptysie. L’anastomose atrio-veineuse etait permeable.

Resume Introduction Les stents peripheriques nus sont utilises dans le traitement des stenoses arterielles symptomatiques. La technique mini-invasive de pose de ce materiel a permis de diminuer la morbidite postoperatoire par rapport a la chirurgie prothetique par abord direct, surtout d’un point de vue infectieux. Nous rapportons ici le cas d’une infection d’endoprothese vasculaire apres angioplastie au ballon actif justifiant une revue de la litterature. Materiel et methode Nous avons observe une infection d’une endoprothese femorale superficielle en nitinol deux semaines apres une recanalisation endoluminale a l’aide d’un ballon actif au paclitaxel. Le diagnostic a repose sur la clinique, la realisation d’un TEP-scanner et des hemocultures repetees positives a Propionibacterium granulosum. Le traitement a comporte une antibiotherapie intraveineuse et l’ablation chirurgicale de l’endoprothese vasculaire. La patiente est sortie sous antibiotherapie adaptee pour une duree de 3 mois. L’arret des antibiotiques a ete conforte par le TEP-scanner de controle. Nous avons realise une revue de la litterature (PubMed et Cochrane) rapportant tous les cas d’infection d’endoprothese peripherique arterielle et recherche le role etiologique des ballons actifs dans la survenue de cette complication. Resultats Il ressort 49 cas d’infection d’endoprothese arterielle peripherique en incluant notre patiente. Il s’agit d’une complication rare mais grave avec une mortalite de 30 % et 25 % d’amputation. L’incidence de cette complication semble etre sous-estimee. Le traitement repose sur l’ablation chirurgicale du materiel, les traitements conservateurs etant greves d’une mortalite importante. L’impact du ballon actif a l’origine de l’infection reste imprecis meme si plusieurs auteurs suspectent qu’il puisse induire une immunosuppression locale. Conclusion Nous presentons le premier cas d’infection d’endoprothese arterielle apres recanalisation au ballon actif. Cette complication, dont le pronostic fonctionnel et vital est severe, reste rare et difficile a diagnostiquer, les signes cutanes etant souvent au premier plan.

The anatomy of the trachea lymphatics is poorly understood and the only researches date back to more than one century. Tracheal tumors are very rare, miscellaneous and variously lymphophilic. The cancers of the trachea have no TNM and their lymph node metastases are little studied despite their poor prognosis. We observed 2 cases of squamous cell carcinoma, one in the cervical and the other in the intrathoracic trachea. TDM-3D reformats demonstrated metastatic lymph nodes of the right para-tracheal lymph node chain (2R and 4R) in both patients and in the cervical lymph nodes (right recurrent nerve lymph node chain) in the patient with cervical tumor. Right location of the mediastinal metastases may be explained by the anatomy of the lymph node chain drainage of the lung segments, the right para-tracheal chain being the only one to regularly possess lymph nodes at that level. The right recurrent nerve lymph node metastases of the cervical tumor are explained by common lymph drainage of the cervical trachea towards larynx lymph centres. Besides lymph node metastases, cancers prognosis may also depends on its location in the trachea. Thus, the tracheal tumors are complex and constitute quite as many orphan tumors. Multicentric studies are mandatory to better understand their behavior. Means provided by new imaging techniques might permit establishing a veritable TNM lymph node mapping of these tumors.

A 64-year-old man complained of persistent dyspnea and bilateral basi-thoracic pain with shoulder irradiation. Chest computed tomography revealed a heterogeneous left diaphragmatic mass, while magnetic resonance imaging showed hypo-T1 and hyper-T2 signal. Positron-emission tomography did not show any hypermetabolism. Video-assisted thoracic surgery was decided. At inspection, tumour appeared within the posterior costal part of the diaphragmatic muscle. Tumour resection was extended to a 8-cm-long portion of the lumbar part of diaphragm. Diaphragm was repaired with non-absorbable interrupted sutures. Postoperative course was uneventful. Final pathology revealed an intra-diaphragmatic bronchogenic cyst, which is an exceptional condition. Primary diaphragmatic tumours are very rare and preoperative diagnosis cannot be affirmed. Embryologic hypotheses (migration along the oesophagus or envelopment within diaphragmatic precursors of an abnormal supernumerary lung bud) including recent molecular findings of deregulated pathways (fibroblast growth factor-10 and NOTCH) are discussed.

Resume Les therapies ciblees ont considerablement ameliore le pronostic des patients atteints d’un cancer du rein metastatique (CCRm) mais on ne dispose pas de criteres d’evaluation de reponse fiables refletant les benefices cliniques car la regression en taille est absente ou retardee. Ces criteres permettraient l’identification precoce des non-repondeurs qui beneficieraient alors d’un changement therapeutique et leur eviteraient d’inutiles effets secondaires lies au traitement. Nous passerons en revue les techniques d’imagerie actuellement disponibles pour l’evaluation de la reponse tumorale chez les patients CCRm, dont les criteres de reponse des tumeurs solides (RECIST), les criteres Choi, les criteres Choi modifies, et les criteres de densite et de taille en CT (SACT). Nous aborderons aussi les techniques d’imagerie fonctionnelle qui se basent sur les caracteristiques physiologiques des tumeurs telles que le scanner, l’imagerie par resonance magnetique ou l’echographie de perfusion (DCE-CT, DCE-MRI, DCE-US), l’IRM de diffusion, l’IRM par effet BOLD et les nouveaux traceurs en tomographie par emission de positons (TEP). Il n’est pas possible actuellement de proposer un critere unanimement reconnu pour l’evaluation de la reponse tumorale aux therapies dites ciblees. Cependant, il s’agit d’un besoin reel exprime par les oncologues et les industriels, et les radiologues doivent s’impliquer dans cette reflexion.

The clinical presentations of diaphragm dysfunctions vary according to etiologies and unilateral or bilateral diseases. Elevation of the hemidiaphragm from peripheral origins, the most frequent situation, requires a surgical treatment only in case of major functional impact. Complete morphological and functional analyses of the neuromuscular chain and respiratory tests allow the best selection of patients to be operated. The surgical procedure may be proposed only when the diaphragm dysfunction is permanent and irreversible. Diaphragm plication for eventration through a short lateral thoracotomy, or sometimes by videothoracoscopy, is the only procedure for retensioning the hemidiaphragm. This leads to a decompression of intrathoracic organs and a repositioning of abdominal organs without effect on the hemidiaphragm active contraction. Morbidity and mortality rates after diaphragm plication are very low, more due to the patient's general condition than to surgery itself. Functional improvements after retensioning for most patients with excellent long-term results validate this procedure for symptomatic patients. In case of bilateral diseases, very few bilateral diaphragm plications have been reported. Some patients with diaphragm paralyses from central origins become permanently dependent on mechanical ventilation whereas their lungs, muscles and nerves are intact. In patients selected by rigorous neuromuscular tests, a phrenic pacing may be proposed to wean them from respirator. Two main indications have been validated: high-level tetraplegia above C3 and congenital alveolar hypoventilation from central origin. After progressive reconditioning of the diaphragm muscles following phrenic pacing at thoracic level, more than 90% of patients can be weaned from respirator within a few weeks. This weaning improves the quality of life with more physiological breathing, restored olfaction, better sleep and better speech. The positive impact of diaphragm stimulation has also been evaluated in other degenerative neurological diseases, particularly the amyotrophic lateral sclerosis. For either central or peripheral diaphragm dysfunctions, a successful surgical treatment lies on a strict preoperative selection of patients.

Resume Le role de la circulation lymphatique en transplantation pulmonaire (TPx) a ete peu analyse depuis les premiers modeles animaux ayant permis l’essor des transplantations d’organes solides. Pourtant, les phenomenes œdemateux observes dans les greffons au decours immediats d’une TPx demeurent souvent imprevisibles et inexpliques alors qu’ils font partie integrante de l’entite appelee « defaillance primaire du greffon ». Si leurs caracteres multifactoriels rend difficile leur interpretation, l’hypothese d’un bouleversement du circuit de la lymphe intervenant dans la genese de ces phenomenes œdemateux est avancee. L’analyse du bouleversement de ces voies lymphatiques a essentiellement ete faite sur des modeles animaux de transplantation d’intestin grele presentant des similitudes interessantes avec la TxP. Les points analyses ont ete les consequences de l’interruption des canaux lymphatiques ainsi que leurs modalites de regeneration apres transplantation. Le role immunologique des lymphatiques dans la mediation du rejet, la reponse immunitaire locale du poumon et dans la survenue de la bronchiolite obliterante ont egalement ete evalues dans la TPx. Cette revue a permis de faire la synthese des etudes ayant aborde la problematique des courants lymphatiques en transplantation.

Introduction Il n’existe pas de recommandation concernant l’evaluation preoperatoire des eventrations diaphragmatiques. L’objectif de cette etude a ete d’evaluer l’interet de l’IRM dynamique du diaphragme faite avant et apres plicature de coupole, en developpant des criteres standardises d’analyse. Methodes De 2006 a 2017, 18 patients (Gp1) operes d’une eventration diaphragmatique unilaterale gauche (Gp1L, n = 15) ou droite (Gp1R, n = 3) ont eu une evaluation pre- et post-operatoire incluant une IRM dynamique. Cinq volontaires sains ont aussi eu cet examen. La course diaphragmatique au niveau de 3 points fixes (S1-S2-S3) et l’evolution perioperatoire de la fleche de chaque coupole (n = 41) en vue sagittale ont ete les 2 criteres principaux d’analyse. Resultats Sur l’IRM preoperatoire, toutes les coupoles avec une eventration (Gp1) avaient une course significativement reduite voire nulle en comparaison avec leur cote sain (p Figure 1 ). Conclusion L’IRM dynamique est un examen non invasif qui parait utile pour ameliorer nos connaissances en eventrations unilaterales du diaphragme et evaluer nos resultats chirurgicaux. Bien qu’il s’agisse d’une petite serie de patients, cet examen nous permet de valider l’existence d’un impact negatif significatif de l’eventration unilaterale sur la coupole saine controlaterale. Il met en lumiere le benefice local et controlateral de la plicature diaphragmatique. La grille standardisee que nous avons developpee peut aider les cliniciens dans leur approche chirurgicale et leurs futures evaluations.

The acetabular cup (AC) is an implant impacted into a bone cavity and used for hip prosthesis surgery. Initial stability of the AC is an important factor for long term surgical success. The aim of this study is to determine the variations of the impact duration during AC implant insertion. Twenty-two bone samples taken from bovine femurs were prepared ex vivo for the insertion of an acetabular cup implant, following the surgical procedure used in the clinic. For each bone sample, ten impacts were applied using reproducible mass falls (3.5 kg) in order to insert the AC implant. Each impact duration was recorded using a wide bandwidth force sensor. For all bone samples, the impact duration was shown to first decrease as a function of the impact number, then reaching a stationary value equal in average to 4.2±0.7 ms after an average number of 4.1±1.7 impacts. The impact duration may be related to variations of the bone-implant interface contact rigidity because of an increase the amount of bone tissue in contact with the AC implant. Measurements of impact duration have a good potentiality for clinical application to assist the surgeon during the insertion of the AC implant, providing valuable information on the bone-implant interface contact properties.

Introduction Le succes a long terme des protheses totales de hanche non cimentees depend de la stabilite primaire de l’implant acetabulaire (IA). Cette stabilite doit etre suffisante pour eviter des micromouvements a l’interface os-implant. Toutefois, les contraintes dans le tissu osseux autour de l’IA doivent etre suffisamment faibles afin de diminuer les risques de fracture pendant l’impaction. Cependant, il reste difficile d’evaluer de maniere fiable la stabilite primaire de l’IA pendant l’operation, du fait notamment de la complexite de l’interface os-implant. L’objectif de cette etude est de developper une technique d’analyse d’impact permettant d’estimer la stabilite primaire de l’IA et d’evaluer ses performances a travers une etude cadaverique. Materiel et methodes Plusieurs tailles d’IA ont ete inserees successivement dans 23 hanches de sujets anatomiques humains selon le meme protocole employe en clinique menant a 127 configurations differentes. Le marteau utilise pour l’impaction a ete instrumente avec un capteur de force afin de mesurer la force en fonction du temps lors de l’impact entre le marteau et l’ancillaire. Un indicateur I a ete calcule pour chaque impact a partir du signal de force. Pour chaque configuration, 12 impacts ont ete realises dans le but d’obtenir la valeur moyenne Im de l’indicateur. Enfin, la force d’arrachement tangentiel F a ete mesuree en mettant en œuvre un test d’arrachement tangentiel. Resultats Sur l’ensemble des donnees, une correlation significative (R2 = 0,71) a ete trouvee entre l’indicateur moyen Im obtenu a partir des signaux et la force d’arrachement F qui correspond a la stabilite biomecanique de l’implant. Ces resultats signifient qu’il est possible d’obtenir une estimation fiable de la stabilite d’IA a partir d’impacts legers realises a l’aide d’un marteau instrumente sur l’ancillaire. Cette methode de mesure permet de s’appuyer sur des elements quantitatifs et de confirmer le sentiment du chirurgien actuellement base sur son experience et sur le seul bruit produit lors de l’impact. La methode permet donc de determiner de maniere fiable la stabilite de l’IA. Discussion Ces resultats montrent que la methode d’analyse d’impact developpee permet d’estimer la stabilite biomecanique de l’IA obtenue sur sujets anatomiques. Le principal avantage de cette methode est qu’elle ne modifie en rien le protocole chirurgical. Conclusion Cette etude ouvre une nouvelle voie pour le developpement d’un dispositif medical pouvant etre utilise en peroperatoire dans le but d’aider le chirurgien a adapter sa strategie chirurgicale dans le cadre d’une approche personnalisee pour chaque patient.

Non-union fracture is a pathological condition having some impairment of the cellular part of the repair: a reduction of MSC and of the osteoblastic activation. Non union is therefore a good indication for cell-based therapies using stem cells. We described the rational of this treatment and described the technique of autologous bone marrow concentrate implantation that was until now used. With the development of stem cell research and regenerative medicine, we believed that therapy based on cytotherapy has great potential. In this review, clinical applications of cytotherapy are summarized and analyzed. Current problems and future challenges are discussed.