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Resume Toute scoliose evolutive doit etre traitee efficacement. La kinesitherapie est utile, mais seule, elle est insuffisante. Le traitement orthopedique par corset permet de ralentir l’aggravation de la deformation. En cas d’echec ou de difficultes liees a la compliance du patient, l’evolutivite de la deformation peut rapidement rendre celle-ci inacceptable, des l’adolescence ou, a plus long terme, a l’âge adulte. Il est alors necessaire de proposer un traitement chirurgical avec une instrumentation permettant une correction de la deformation et une greffe osseuse assurant sa stabilisation. Ces interventions, pratiquees selon des regles strictes, donnent des resultats satisfaisants et autorisent une vie strictement normale, a condition de conserver une mobilite lombaire residuelle suffisante.

Neuropathic arthropathy of the spine is a destructive condition of the spine which is secondary to a loss of the protective proprioceptive reflexes. In the majority of cases, it occurs in patients who have suffered from traumatic medullary lesions and is responsible for destruction of the vertebral bodies and considerable spinal deformity. We report a case of neurogenic lumbar arthropathy in a patient with a spinal arteriovenous malformation. This vascular lesion caused considerable disturbances of proprioception. The course was favorable with regard to the deformity after correction and fusion by posterior approach.

Resumen Cualquier escoliosis evolutiva debe tratarse de modo eficaz. La fisioterapia es util pero por si sola resulta insuficiente. El tratamiento ortopedico mediante corse permite hacer mas lento el empeoramiento de la deformacion. En caso de fracaso o de dificultades relacionadas con el cumplimiento por parte del paciente, la evolucion de la deformacion puede hacer que, a partir de la adolescencia, o a mas largo plazo, en la edad adulta, esta se vuelva inaceptable. En este caso resulta necesario proponer un tratamiento quirurgico con una instrumentacion que permita la correccion de la deformacion y un injerto oseo que asegure su estabilizacion. Estas intervenciones, practicadas de acuerdo con normas estrictas, proporcionan resultados satisfactorios y permiten una vida totalmente normal, a condicion de que se mantenga una movilidad lumbar residual suficiente.

Resumen La escoliosis idiopatica aparece en ninos en perfecto estado de salud y sin ninguna causa aparente. Se trata de una deformacion progresiva de la columna en los tres planos del espacio, que tiene como consecuencia una rotacion vertebral que produce una gibosidad y una modificacion del equilibrio sagital del tronco. El diagnostico de escoliosis es facil mediante la simple exploracion del tronco inclinado hacia adelante, que pone en evidencia la gibosidad y permite descartar gran numero de «actitudes escolioticas». La escoliosis tiene un riesgo de agravamiento, especialmente claro durante el periodo de crecimiento. En la pubertad, la escoliosis puede evolucionar en ocasiones hacia una deformacion importante, sobre todo en caso de escoliosis que aparecen en etapas iniciales de la infancia. Hay que vigilar atentamente todos los casos de escoliosis, al menos dos veces al ano, durante el periodo de crecimiento.

The foot may be the site of birth defects. These abnormalities are sometimes suspected prenatally. Final diagnosis depends on clinical examination at birth. These deformations can be simple malpositions: metatarsus adductus, talipes calcaneovalgus and pes supinatus. The prognosis is excellent spontaneously or with a simple orthopedic treatment. Surgery remains outstanding. The use of a pediatric orthopedist will be considered if malposition does not relax after several weeks. Malformations (clubfoot, vertical talus and skew foot) require specialized care early. Clubfoot is characterized by an equine and varus hindfoot, an adducted and supine forefoot, not reducible. Vertical talus combines equine hindfoot and dorsiflexion of the forefoot, which is performed in the midfoot instead of the ankle. Skew foot is suspected when a metatarsus adductus is resistant to conservative treatment. Early treatment is primarily orthopedic at birth. Surgical treatment begins to be considered after walking age. Keep in mind that an abnormality of the foot may be associated with other conditions: malposition with congenital hip, malformations with syndromes, neurological and genetic abnormalities.

Resume Les infections a cytomegalovirus (CMV) sont classiques dans les cas d’immunodepression severe. Nous rapportons un cas d’atteinte digestive isolee chez une jeune malade initialement immunocompetente. La malade presentait un etat de choc secondaire a une pneumopathie d’inhalation puis une enterocolite dont l’origine restait inexpliquee pendant pres de trois semaines. L’evolution etait marquee par la necessite de realiser plusieurs gestes de resections digestive avant de parvenir au diagnostic. L’examen anatomopathologique etait a l’origine du diagnostic dans le cas que nous rapportons. Le diagnostic histologique etait confirme par marquage immuno-histochimique et par la cinetique de l’antigenemie et des anticorps circulants anti-CMV. Nous insistons sur les differentes caracteristiques de cette pathologie qui peut avoir de graves consequences si elle reste longtemps meconnue.

A diagnosis of constrictive pericarditis is suggested by the presence of pericardial thickening (=4 mm in thickness) and abnormal motion of the interventricular septum. Additional findings have been reported: tubular appearance of the right or left ventricles, dilatation of the vena cava, atrial dilatation or abnormal diastolic expansion of one or both ventricles. In patients with suspected chronic pericarditis, CT can more easily demonstrate the presence of pericardial calcifications compared to US and MRI, as well as detect the presence of mediastinal adenopathy and lung lesions, suggesting tuberculosis. Septal motion analysis should be performed during protodiastole and systole using a cine technique with both CT and MR.

Experimental animal study.To evaluate motor and sensitive axonal regrowth after multiple intercosto-lumbar neurotizations in a sheep model.France.Fifteen sheep were separated into three groups. Five sheep had multiple intercosto-lumbar neurotizations and a spinal cord lesion, five sheep were neurotized without any spinal cord lesion and five sheep had a spinal cord lesion without any neurotizations. Six months after the initial surgery, histological study of the neurotized roots was performed.The length of the three rerouted intercostal nerves was sufficient in the 10 sheep to perform an intercosto-lumbar neurotization in good conditions. Eight sheep out of the 15 had postoperative complications responsible for the animal's death in five cases. Histological cross-sections of all the neurotized L2, L3 and L4 roots showed numerous myelinated regenerated axons. Dorsal root ganglions of neurotized roots showed both large and small neurons with normal nucleus and cytoplasm. The fluorescent retrograde labeling of 18 roots revealed labeled motor neurons in five cases.This study demonstrates the technical feasibility of intercosto-lumbar neurotizations in a big mammalian model. Intercostal nerve harvesting and rerouting was successfully performed in all the cases. Our histological results proved, in all the animals studied, the ability of motor and sensitive neurons to regenerate through the neurotization area. In the context of the future clinical application of strategies aimed at promoting axonal regeneration after severe spinal cord injury, the present data suggest that multiple intercosto-lumbar neurotization could be helpful to promote lower limb muscular strength recovery after spinal cord injuries.

Biographie En 60 ans de carriere, Gratien Gelinas s'est impose comme l'un des «monstres sacres» du theâtre et de la dramaturgie au Canada. Autodidacte, il a du abandonner ses etudes en raison de la crise economique qui sevissait en 1929. Il a neanmoins connu une carriere artistique remarquable. «Pere» du theâtre quebecois, ne a Saint-Tite-de-Champlain le 8 decembre 1909, Gratien Gelinas, autodidacte, fait du theâtre amateur avec la section francaise du Montreal Repertory Theatre, puis avec une troupe qu'il fonde avec les anciens du College de Montreal. En mai 1936, il amorce sa carriere de comedien professionnel comme monologuiste dans Televise-moi ca, revue de Louis Francoeur et Jean Beraud. Il cree a la radio le personnage de Fridolin, qui monte sur la scene du Monument-National le 3 mars 1938 et devient, jusqu'en 1946, le personnage central des revues Fridolinons, rassemblees et publiees sous le titre de Les Fridolinades. Pendant la guerre, il fonde la compagnie de cinema Excelsior puis, en 1957, la Comedie-Canadienne, qu'il dirige jusqu'en 1972. De 1969 a 1978, il est president de la Societe de developpement cinematographique. En plus de ses pieces, jouees dans plusieurs pays, il a ecrit pour la television (Les Quatre fers en l'air). Nous avons pu le voir au cinema (Les Tisserands du pouvoir) et a la scene dans sa toute derniere piece La Passion de Narcisse Mondoux, dont il a donne au-dela de 300 representations. Membre de la Societe royale du Canada depuis 1958, il s'est vu decerner plusieurs doctorats honorifiques. Il a recu en 1967 le prix Victor-Morin et la medaille de l'Ordre du Canada, celle de l'Academie canadienne-francaise et le prix international de l'Ecriture qu'accordait pour la premiere fois la maison Dupont, de Paris, en 1989. De 1969 a 1978, Gratien Gelinas preside la Societe de developpement de l'industrie cinematographique canadienne, qui deviendra Telefilm Canada. Durant les annees quatre-vingt, il joue dans Red, de Gilles Carle, dans Bonheur d'occasion, Claude Fournier et dans Agnes of God, de Norman Jewison, aux cotes de Jane Fonda et Ann Bancroft. En 1990, le titre de personnalite de l'annee lui etait decerne par le journal La Presse. SRC/Stanke publiait en 1993 Gratien, Tit-Coq, Fridolin, Bousille et les autres, des entretiens entre Gelinas et Victor-Levy Beaulieu. En 1991, le Centre des auteurs dramatiques creait le Fonds Gratien Gelinas pour promouvoir la dramaturgie quebecoise. Gratien Gelinas est decede le 16 mars 1999.

Most of gallbladder tumors are benign. Adenoma, cholesterol polyps, or adenomyomatosis are most frequently typical on ultrasonographic images. All symptomatic lesions must be considered as indications for surgery. It may be difficult to identify precancerous or malignant lesion. Polyps over 1cm are indication for preventive cholecystectomy. In case of suspicious polyp or suspicious wall thickening, endoscopic ultrasonography can be helpful to evaluate local tumoral spread and eliminate differential diagnosis. Unfortunately, diagnosis of gallbladder cancer is often late, when surgical resection can't be curative. Computed tomography and magnetic resonance imaging examinations are then useful for local and metastatic staging.

STUDY DESIGN Descriptive anatomy. OBJECTIVE.: To describe the anatomy associated with the extensive transmuscular paraspinal approach required to perform multiple intercosto-lumbar neurotizations. SUMMARY OF BACKGROUND DATA Neurotization of lumbar roots using lower intercostal nerves is a potential method of treating neurologic deficits after spinal cord injury. It appeared to us that the paraspinal splitting approach was potentially an optimal method to perform intercostal nerve harvesting, rerouting, and intercosto-lumbar neurotizations. METHODS Ninth, 10th, and 11th intercostal nerve harvesting and rerouting down to L2, L3, and L4 roots were performed on 50 cadavers. The descriptive anatomy and topographic landmarks are reported. RESULTS The mean total length of intercostal nerve harvested was 17.96 (range, 10-27) cm for the 9th intercostal nerve, 17.14 cm (range, 10-20) for the 10th intercostal nerve and 15.94 cm (range, 10-25) for the 11th intercostal nerve. The length of harvested nerve was not correlated to the size of the trunk. The length of harvested nerve was sufficient to perform lumbar roots neurotizations in the 300 cases of nerve harvesting. CONCLUSION Multiple lumbar roots neurotizations with lower intercostal nerves already have been proposed by other authors. In this strategy, the use of the spinal cord and intercostal nerves above the spinal cord lesion avoids the axonal regrowth required via the injured central nervous system. Rerouting intercostals nerves down to the lumbar roots at their exit from the intervertebral foraminae is less invasive that the same procedure performed down to the vertebral canal at the level of the cauda equina as we used in previous protocols. Our anatomic study confirms the advantage of the paraspinal sacrospinalis splitting approach in multiple intercosto-lumbar neurotizations. The approach is quick and easy and allows a good exposure of the nerve roots at the thoracic and lumbar levels. The L2, L3, and L4 roots could be satisfactorily neurotized with this procedure.

Introduction Neurotization of lumbar roots with lower intercostal nerves is a potential way to treat neurological deficits after spinal cord injury. The anatomical feasibility of such neurotizations in humans has already been reported. We propose to assess axonal regrowth after intercostal to lumbar neurotization in a sheep model. Materials and methods Ten sheep had a left T11-L2, T12-L3, and T13-L4 neurotization. In 5 sheep, a L1 level left hemisection of the spinal cord was performed. The sheep had clinical and electrophysiological monitoring with a 6 mon follow-up. Results A flaccid paralysis with clinical asymmetry of the left abdominal wall was noted three months after surgery. This asymmetry improved in all the cases at the 6 mon follow-up. Motor potentials were detected without difficulty for the 3 neurotized nerves (L2, L3, and L4) in 5 sheep. In another sheep, motor potentials of the L3 root remained undetected. Eight sheep had postoperative complications responsible for the animals' death in 5 cases. Conclusions The current study demonstrates the technical feasibility of intercosto-lumbar neurotizations in a sheep model. We proved in all the animals—except in the case of 1 neurotized root—the ability of motor axon to regenerate through neurotization area down to the muscular effectors; however, we noted a high rate of postoperative complications in this animal model.

Tillaux fractures in adolescents correspond to Salter and Harris type III fractures involving the anterolateral portion of the tibial epiphysis. These are intra-articular fractures. The objective was to determine the circumstances of these fractures, the radiological signs, and the therapeutic modalities as well as the long-term clinical and radiological outcome.We reviewed 19 Tillaux fractures. Ten patients underwent surgical treatment and nine orthopedic treatment following importance of displacement.At mean follow-up of 33.8 months, results were rated good in 17 on 19 cases.This fracture is often observed in teenagers victims of trauma with external rotation of the foot. Closure of distal growth cartilage of the tibia occurs medially to laterally, the anterolateral portion remaining open longer. Forced external rotation of the anterior tibiofibular ligament pulls off an anterolateral fragment of the distal tibial epiphysis. Surgical treatment is indicated for fractures with a displacement of more than 2 mm or a vertical displacement to achieve open reduction and screw fixation. Orthopedic treatment is used for non-displaced fractures.The prognosis of Tillaux fractures is good as was observed in our series and in series reported in the literature.

Object The topographic anatomy of the lower intercostal nerves is less well known than that of the upper ones, except for the 12th intercostal nerve. It is possible to use the lower intercostal nerves to perform a neurotization of the lumbar roots. The authors studied the anatomy of the ninth, 10th, and 11th intercostal nerves to obtain descriptive and topographic anatomical data to aid in establishing optimal conditions for harvesting. Methods The ninth, 10th, and 11th intercostal nerves of 50 cadavers were dissected. The proximal part of the nerve in the posterior intercostal space (ISC) was exposed through a posterior approach. The lateral ICS was exposed through a lateral approach, under the latissimus dorsi, which made it possible to harvest the intercostal nerves using a stripping technique. A histological study was conducted on 10 pigs to evaluate the risk of nerve lesions during the stripping procedure. Conclusions The proximal course of the nerve in the posterior ICS was the same in all cases. The mean total length of the intercostal nerves harvested was 17.96 cm for the ninth, 17.14 cm for the 10th, and 15.94 cm for the 11th intercostal nerve. The harvested nerve length was sufficient in 297 of the 300 cases to perform lumbar root neurotization. The histological study showed no difference between the “open” and the “stripping” techniques regarding the risk of histological lesions in harvested nerves.

The paraspinal posterior approach to the lumbar spine initially was described for spinal fusion, particularly for treatment of lumbosacral spondylolisthesis. Despite the technical details described by Wiltse et al, the exact location of the sacrospinalis muscle that must be split remains unclear. We sought to clarify the anatomic description of the paraspinal posterior approach to the lumbar spine, and to provide topographic landmarks for facilitating this surgical approach. Fifty cadavers were dissected using an anatomic transmuscular paraspinal approach. The level of the natural cleavage plane between the multifidus and the longissimus parts of the sacrospinalis muscle was noted, and measurements were taken between this level and the midline at the level of the spinous process of L4. A natural cleavage plane between the multifidus and the longissimus parts of the sacrospinalis muscle was present in all specimens. There was a fibrous separation between the two muscular parts in 88 of 100 cases. The mean distance between the level of the cleavage plane and the midline was 4.04 cm (range, 2.4-7 cm). Small arteries and veins were present at the level of the cleavage plane in all specimens. These vascular landmarks make it easier to locate the muscular cleavage plane and reach the articular and transverse processes during the paraspinal approach.

Introduction Le substitut dermique (Hyalomatrix® PA) permet une reepithelialisation chez les jeunes enfants. Nous l’avons utilise dans le traitement chirurgical des syndactylies en alternative aux greffes de peau totale. Materiel et methodes Nous avons suivi de facon prospective, 20 patients de moins de 20 mois (32 commissures) atteints de syndactylie complete congenitale (22 simples et 10 complexes). Tous les patients ont eu une liberation commissurale avec un lambeau omega-ancre de marine et des plasties en Z sur les faces laterales des doigts. Dix patients (17 commissures) ont eu un pansement avec un substitut dermique (Hyalomatrix® PA) sans greffe de peau (groupe 1). Dix patients (15 commissures) ont ete operes selon la methode classique utilisant des greffes de peau totale (groupe 2). Le pansement etait refait a 3 semaines. L’analyse statistique a ete effectuee avec le test de correlation de Pearson. Resultats L’âge moyen au moment de l’intervention etait de 11 mois (6–19). Le suivi moyen etait de 16 mois (13–21). Le temps operatoire etait de 50 min (38–64) dans le groupe 1, et de 92 min (71–122) dans le groupe 2 (p

Several reports have examined the pathophysiology of degenerative spondylolisthesis. Very little work has however been devoted to the influence of spinal balance in the sagittal plane in its pathogenesis. The purpose of this work was to present a descriptive analysis of pelvic and spinal sagittal balance in a cohort of seventy patients treated for degenerative spondylolisthesis and to compare findings with those established in a population of 250 volunteers. The goal was to deduct pathophysiological hypotheses and identify therapeutic implications.Seventy patients were included in this study. The following variables were noted: pelvic incidence and version, sacral slope, lumbar lordosis, thoracic kyphosis, T9 sagittal tilt and S1-S2 angle. These variables were measured on digitalized lateral views of the spine using a dedicated software (SpineView). Univariate analysis of the values obtained was performed to identify the variable distributions. Multivariate analysis was applied to study the relationships between these variables and to better define perturbations of spinal balance in the anteroposterior plane. The findings were compared with those obtained in a control population.One of the essential characteristics of the cohort of patients with degenerative spondylolisthesis was the presence of an exaggerated pelvic incidence (62.6 degrees versus 54.7 degrees in the control population). The most significant determinants of T9 sagittal tilt (which reflects sagittal balance) were: pelvic version, pelvic incidence, lumbar lordosis, and L4-S1 local lordosis. One-third of our patients presented posterior tilt due to exaggerated thoracic kyphosis. The high pelvic incidence, via hyperlordosis and increased pelvic version, could be one of the factors favoring degenerative disease of the spinal unit.This work enabled us to better describe sagittal balance in patients with degenerative spondylolisthesis and to propose hypotheses concerning the underlying mechanism of progressive degeneration. We emphasize the diversity of spinal balance in these patients and the different therapeutic implications.

Neuropathic arthropathy of the spine is a destructive condition of the spine which is secondary to a loss of the protective proprioceptive reflexes. In the majority of cases, it occurs in patients who have suffered from traumatic medullary lesions and is responsible for destruction of the vertebral bodies and considerable spinal deformity. We report a case of neurogenic lumbar arthropathy in a patient with a spinal arteriovenous malformation. This vascular lesion caused considerable disturbances of proprioception. The course was favorable with regard to the deformity after correction and fusion by posterior approach.

Tear-drop fracture of the axis is an exceptional spinal fracture which generally occurs after high-energy trauma with hyper-extension of the cervical spine. Purely anterior fracture can occur with no real impact on stability. Orthopedic treatment provides good results in this situation. If the fracture is posterior, it continues into the C2-C3 intervertebral disc and the common posterior vertebral ligament, leading to C2C3 instability and possible retrolisthesis of C2 over C3 and neurological involvement. We report a case of tear-drop fracture of C2 with C3 instability without neurological involvement. This patient underwent posterior fixation with C2C3 arthrodesis which provided good quality bone fusion without secondary displacement or clinical aggravation.

The original description of the paraspinal posterior approach to the lumbar spine was for spinal fusion, especially regarding lumbosacral spondylolisthesis treatment. In spite of the technical details described by Wiltse, exact location of the area where the sacrospinalis muscle has to be split remains somewhat unclear. The goal of this study was to provide topographic landmarks to facilitate this surgical approach. Thirty cadavers were dissected in order to precisely describe the anatomy of the trans-muscular paraspinal approach. The level of the natural cleavage plane between the multifidus and the longissimus part of the sacrospinalis muscle was noted and measurements were done between this level and the midline at the level of the spinous process of L4. A natural cleavage plane between the multifidus and the longissimus part of the sacrospinalis muscle was present in all cases. There was a fibrous separation between the two muscular parts in 55 out of 60 cases. The mean distance between the level of the cleavage plane and the midline was 4 cm (2.4–5.5 cm). In all cases, small arteries and veins were present, precisely at the level of the cleavage plane. We found it possible to easily localize the anatomical cleavage plane between the multifidus part and the longissimus part of the sacrospinalis muscle. First the superficial muscular fascia is opened near the midline, exposing the posterior aspect of the sacrospinalis muscle. Then, the location of the muscular cleft can be found by identifying the perforating vessels leaving the anatomical inter-muscular space.

Diagnosis, physiopathology, and treatments of four patients with traumatic lumbosacral dislocations are described. This is a rare but severe lesion of the lumbosacral junction that usually occurs in patients with multiple trauma. It often is not thought of and the diagnosis may be missed. Evidence of lumbosacral dislocation should be examined and confirmed by computed tomography scans in patients with multiple fractures of transverse lumbar processes, asymmetric lumbosacral joints on frontal images, or slipping of L5 over S1 on lateral images. Treatment consists of reduction of the dislocated and fractured parts, lumbosacral arthrodesis, a posterolateral graft, and posterior instrumentation. Instrumentation may be short, extending from L5 to S1, or long, from L4 to S1, depending on the extension of the lesion. In some cases, reduction can be done intraoperatively, when the L4-S1 instrumentation is inserted, provided L5 transpedicle screws are pulled posteriorly. It usually is preferable to explore the vertebral canal to ensure that there is no disc lesion compressing the dura before proceeding with reduction. Compression of the dura could be avoided with a preoperative magnetic resonance imaging scan on which a lesion of the L5-S1 disc is sought. Additional interbody vertebral arthrodesis should be considered when the L5-S1 disc is affected severely. This lesion should be looked for preoperatively with a magnetic resonance imaging scan and intraoperatively by exploring the canal. This can be done at the time of the posterior surgery or during a second anterior surgical procedure.

Nocardia spp. cerebral abscesses are rare and usually occur in immunocompromised patients. We report two recent cases of cerebral abscesses due to Nocardia farcinica in immunocompetent patients and review the literature about diagnosis and therapeutic issues. Outcome was good for the two patients following an early identification of the bacteria. Stereotactic biopsy was performed in one case and craniotomy with excision of the abscess in the other case. In both cases, complete identification of the bacteria could be achieved, followed by prolonged antibiotic therapy. Exposure to the germ (mainly telluric) is often difficult to suspect from the past medical history of the patient. Diagnosis is also unexpected. Despite the typically and characteristic aspect on CT and MRI, specific identification and anti-microbial sensitivity profiles are necessary to optimize treatment. In some rare cases, unusual species like Nocardia farcinica, can be resistant to numerous antibiotics requiring adjustments of medical management. Early identification of the bacteria is necessary to achieve good outcome in immunocompetents patients.

Synovial cyst of the intercondylar fossa of the knee or cyst of the "cruciate tentorium" is an uncommon finding. Most of the reports in the literature were made after the advent of magnetic resonance imaging. Most cysts are asymptomatic and discovered fortuitously. We report our experience with three cases of symptomatic cysts, describing the diagnostic and therapeutic approaches used. Clinical manifestations of symptomatic cysts are variable and non-specific. Pain is commonly observed with limitation of knee amplitudes. If their is no other suspected meniscal or osteochondral disease after clinical and MRI assessment, surgical treatment is only indicated in case of functional impairment. Medical care may be sufficient in certain cases, associating puncture and infiltration. In others surgical treatment, generally via an arthroscopic approach, is needed.

Colonic location of actinomycosis must be distinguished from infected colonic carcinoma and other colonic inflammatory pseudotumors. The diagnosis is often made by histological examination of the tumor. Initial treatment consists in surgery, followed by an antibiotic treatment. We report the case of a 32-year old woman with a right colonic actinomycosis.

Objectifs Les objectifs de cette etude prospective sont d’une part de definir, pour des sujets sains, les aspects normaux et les limites de l’IRM de diffusion corps entier avec saturation de la graisse (DWIBS) et d’autre part d’evaluer les performances diagnostiques de cette methode par rapport a la TEP-18FDG dans le lymphome. Materiels et methodes Vingt-cinq volontaires sains ont ete etudies par cette technique. Vingt-trois patients suivis pour un lymphome ont beneficie d’une IRM. Celles-ci ont ete comparees a la TEP-18FDG, realisee dans les 48h. Resultats La sequence DWIBS peut montrer, de facon physiologique, des anomalies de signal ganglionnaires (cervicales, axillaires, iliaques et femorales, dont l’ADC moyen est de 1,04 ± 0,14.10 −3 mm 2 /s) et extraganglionnaires (splenique, genital et nerveuse). Chez les patients atteints de lymphomes, la concordance IRM-TEP-18FDG est de 96,7 %, sans aucune difference de staging ann Arbor. La TEP-18FDG est superieure pour l’etude de regions mobiles (hilaires ou mediastinales), alors que l’IRM DWIBS est plus sensible pour la detection d’envahissements osseux. Conclusion Au total, l’IRM DWIBS est un examen dont les performances diagnostiques sont proches de la TEP-18FDG

Objectifs Bilan de l’activite exclusivement cardiologique d’un scanner multidetecteur. Materiels et methodes Revue retrospective de 1500 examens cardiaques realises de janvier 2006 a janvier 2007 sur un scanner a 64 rangees de detecteurs (lightspeed VCT, GE healthcare) au CHU de Poitiers. Resultats Mille cent hommes, 400 femmes, (64 ans ± 14 ans), ont beneficie d’un scanner cardiaque avec synchronisation electrocardiographique. Chez 108 patients, l’injection iodee n’a pas ete effectuee en raison d’un score calcique trop eleve. La recherche de coronaropathie a constitue la principale indication (1400). Six pour cent ont presente un score calcique superieur a mille. Un pour cent a ete totalement ininterpretable en raison de la survenue d’une arythmie en cours d’acquisition. Parmi les complications, on denombre 3 extravasations de produit de contraste resolutives sous traitement medical et aucune reaction allergique severe (les reactions allergiques mineures n’ont pas ete comptabilisees). Chez 18 % des 400 patients sans antecedent de coronaropathie ni test ischemique contributif, au moins une stenose significative (gt ; 50 %) a ete decrite. Une restenose intrastent a ete decrite chez 5 % des 150 patients stentes. Treize pour cent des stents n’ont pas ete analysables (faible calibre, calcifications). Quatre pour cent des 500 ponts etudies ont ete consideres comme stenoses, 18 % comme occlus. Sont egalement presentes 100 bilans pre-operatoires de remplacement de valve cardiaque, 40 scanners realises apres coronarographie douteuse ou incomplete, 30 anomalies de naissance des coronaires, 10 neoformations cardiaques, 9 reseaux veineux coronaires avant implantation d’un stimulateur triple chambre, 20 protheses valvulaires mecaniques, et l’etude des fractions d’ejection ventriculaire gauche. Conclusion Le scanner multicoupe en cardiologie permet de repondre de facon peu invasive aux questions des prescripteurs lorsque les indications sont parfaitement posees.

Arthroscopic lateral retinacular release is one of the most employed procedures for patellar chondromalacia. A literature review show a complication rate of 10 to 18 p. 100 of postoperative hemarthrosis. This work aims to study the vessels anatomy of the lateral side of the knee in order to find anatomical landmarks allowing to avoid or coagulate them.Thirty-three cadaver knees were dissected. Measures were made related to the lateral superior genicular artery and the lateral inferior genicular artery. A study using tracing-paper was also carried out. The main part of the work was more descriptive, studying anastomosis between the different arteries and veins location.Concerning the lateral superior genicular artery, measure analysis showed that this artery was always cut in lateral patellar retinaculum. This artery never runs more than one centimeter proximally to the base of patella, which is too insufficient to escape from lateral retinacular release. We noted the possibility of locating 90 p. 100 of lateral superior genicular arteries in a minimal distance of 15 mm, in front of the lateral proximal angle of the patella. Concerning the lateral inferior genicular artery, only a few arteries, protected in the meniscal wall in its early course, can remain intact. Two thirds of these arteries are very vulnerable running across the lateral side of the knee. The study of the tracing-papers confirmed topographic study measurements. The descriptive study emphasized the number and the importance of anastomoses between these different arteries. Each artery is flanked by two large satellite veins, which also attribute a veinous origin to a possible bleeding.The topographic study of the lateral inferior genicular vessels shows that their course varies. It seems necessary to avoid their division by performing the standard anterior lateral inferior arthroscopic portal proximally to these vessels. This can be realized at the beginning of the procedure through cutaneous transillumination. The lateral superior genicular vessels are always cut. They are nevertheless reachable through a small lateral incision of about 10 mm, distally to the lateral superior angle of the patella. 90 p. 100 at least of these arteries could be coagulated in such a way. We also emphasize the use of classical methods for the prevention of excessive venous bleeding, such as a compression dressing.Following this anatomical study, we suggest, as a supplementary precaution, a selective hemostasis of the lateral superior genicular vessels through a small incision associated with the location of the lateral inferior genicular vessels by cutaneous transillumination.

Objectifs Preciser le role de la tomodensitometrie en haute resolution (TDM-HR) dans le diagnostic des pneumopathies febriles associees a une hypereosinophilie peripherique. Materiels et methodes Les pneumopathies febriles associees a une hypereosinophilie peripherique designent un ensemble d’affections qui comportent divers desordres immunitaires qui ne se discutent qu’apres avoir elimine les principales causes des autres pneumonies a eosinophiles : medicaments, parasites, vascularites. A partir de 6 observations recentes de patients admis en services de Maladies Infectieuses pour pneumopathies febriles associees a une hypereosinophilie peripherique, nous illustrons l’aide au diagnostic apportee par la TDM-HR dans la prise en charge de ces patients. Resultats La TDM-HR couplee a l’histoire clinique des patients a permis d’evoquer : une pneumopathie a eosinophile aux anti-inflammatoires non steroidiens, une aspergillose semi-invasive sur silicose, une localisation pulmonaire d’une distomatose, une localisation pulmonaire d’une anguillulose, 2 vascularites de Churg et Strauss. Ces diagnostics ont ete secondairement confirmes par la biologie. Conclusion L’association des donnees cliniques et radiologiques a permis le diagnostic avant confirmation biologique dans nos 6 observations. Le diagnostic des pneumonies a eosinophiles repose sur un diagnostic differentiel rigoureux et un faisceau d’argument faisant intervenir l’histoire, le tableau clinico-biologique et l’imagerie. Ces pneumonies ont un pronostic tres different les unes des autres. La TDM-HR est particulierement interessante dans la prise en charge diagnostique, des poumons eosinophiles car elle permet d’evaluer les caracteristiques morphologiques et la distribution des lesions pulmonaires parfois tres evocatrice.

Objectifs Connaitre la semiologie en imagerie du cancer de l’estomac (TOGD mais surtout tomodensitometrie). Decrire comment realiser un scanner pour cancer de l’estomac. Connaitre les elements permettant de realiser un bilan pre therapeutique optimal. Decrire les principaux diagnostics differentiels. Messages a retenir L’adenocarcinome primitif de l’estomac represente 95% des tumeurs malignes de l’estomac. L’examen tomodensitometrique est l’examen de reference pour l’etablissement du stade TNM, etape indispensable a l’etablissement du projet therapeutique. Des adenopathies a distance du site gastrique sont considerees comme metastatiques. Les autres tumeurs frequentes sont les GIST et les lymphomes gastriques. Resume Les tumeurs de l’estomac sont principalement malignes et largement dominees par l’adenocarcinome primitif (95% des tumeurs malignes de l’estomac). Malgre une diminution progressive de son incidence depuis 30 ans, les adenocarcinomes gastriques demeurent l’une des dix premieres causes mondiales de mortalite liee au cancer en raison de leur diagnostic souvent trop tardif. Le diagnostic est aujourd’hui essentiellement endoscopique. L’imagerie presente un interet pre therapeutique majeur : la tomodensitometrie doit permettre le bilan d’extension en donnant le stade TNM de la lesion. C’est a partir de cette analyse que seront evaluees les possibilites therapeutiques. Le transit œso-gastro-duodenal ne presente plus d’interet clinique actuellement. Les autres cancers de l’estomac sont beaucoup plus rares et regroupent principalement les lymphomes, les tumeurs gastro-intestinales malignes, les tumeurs carcinoides et les metastases. Ce travail presente les criteres semiologiques pouvant orienter vers ces lesions plus rares. Dans ces lesions, l’imagerie a la encore un role principalement pre-therapeutique et post therapeutique.

Objectifs pedagogiques Connaitre l’anatomie normale des chaines ganglionnaires intra-abdominales. Connaitre les territoires de drainage de chaque groupe ganglionnaire. Savoir reconnaitre une extension ganglionnaire tumorale. Savoir classer cette extension selon les criteres TNM. Messages a retenir Le drainage ganglionnaire abdominal ne beneficie pas d’une systematisation comme pour les ganglions cervicaux ou thoraciques. Il est possible de definir 8 grands territoires de drainage abdominal. Il existe dans chacun de ces territoires des criteres de normalite dont le plus discriminent reste la taille ganglionnaire, mesuree selon le petit axe. Cette taille maximale varie selon le territoire considere. En fonction du territoire ganglionnaire atteint, une tumeur abdominale peut etre classee N+ (c’est-a-dire atteinte ganglionnaire locoregionale) ou M + (c’est-a-dire cancer metastatique).

Objectifs Evaluer les performances de l’echographie de contraste comparativement au scanner multicoupe dans le depistage pre-operatoire des lesions hepatiques secondaires. Materiels et methodes Vingt patients (13 hommes/7femmes) âges entre 43 et 81 ans (âge moyen = 61 ans), devant etre operes de lesions secondaires hepatiques, ont ete inclus prospectivement de janvier 2007 a fevrier 2008. Tous ont beneficie d’une echographie de contraste (Sequoia 512, Siemens Acuson-Sonovue®, Altana) et d’un scanner multicoupe au temps portal apres injection de produit de contraste iode. Une echographie per-operatoire constituait l’examen de reference avec un delai moyen entre la chirurgie et l’examen scano-graphique de 11 jours et un delai moyen entre la chirurgie et l’echographie de contraste de 12,4 jours. Resultats L’echographie per-operatoire a permis de retrouver 46 lesions alors que l’echographie de contraste en avait retrouve 31 (67,4 %) et le scanner 38 (82,6 %). Pour 13 patients, il n’existait pas de discordance entre les 2 examens pre-operatoires. Pour les 7 autres, une lesion en moyenne n’avait pas ete vue en echographie de contraste par rapport au scanner. Conclusion L’echographie de contraste ne constitue pas une exploration substituable au scanner pre-operatoire en cas de chirurgie hepatique pour metastases.

Objectifs Connaitre les aspects radiologiques des principales tumeurs vesiculaires benignes et malignes. Savoir proposer une strategie radiologique a visee diagnostique et pre-therapeutique devant la decouverte d’une masse focale de la vesicule biliaire. Points cles Les tumeurs de la vesicule biliaire les plus frequentes sont benignes. Devant une lesion focale, seules les symptomatiques ou de plus de 10 mm relevent d’une indication de cholecystectomie. Devant un epaississement parietal etandu, une adenomyose doit etre evoquee devant la presence d’artefact en queue de comete en echographie. Parfois difficile a separer d’une lesion maligne, l’IRM est parfois discriminante en cas de visualisation de l’image en collier de perle. Si le doute persiste, une echo-endoscopie peut etre utile pour etudier la paroi vesiculaire. Resume Ce travail presente la confrontation radio-anatomique de 33 cas de tumeurs vesiculaires operees entre 1998 et 2007. Cette revue retrospective est confrontee aux donnees de la litterature. L’adenome se presente comme une formation iso-echogene, sans cone d’ombre posterieur, intra-luminale rattachee a la paroi vesiculaire et fixe lors des manoeuvres de mobilisation du patient. Tout epaississement parietal en regard superieur a 3 mm doit etre considere comme suspect de malignite. L’adenomyose se presente comme un epaississement de la paroi vesiculaire. L’artefact en queue de comete est tres evocateur de cette lesion. L’IRM peut etre utile si elle montre la classique image en « collier de perles ». Le cancer de la vesicule se presente en regle generale comme un syndrome de masse tissulaire heterogene comblant la lumiere et rendant parfois difficile la visualisation precise de ses contours.

Objectifs Decrire in vivo en coroscanner la distribution de l’implantation et du trajet proximal des arteres coronaires dans les trois plans de l’espace. Materiels et methodes Deux cents patients ont beneficie d’un coroscanner 64 detecteurs, injecte, entre aout et octobre 2007. L’implantation des arteres coronaires a ete mesuree en termes de hauteur par rapport a la jonction sinotubulaire et a l’anneau aortique et en termes d’angle par rapport a la commissure anterieure de la valve aortique, de maniere consensuelle par deux radiologues. Resultats En moyenne, l’ostium de la coronaire gauche etait significativement plus proche de la jonction sinotubulaire (3,5 ± 0,34 mm) et de la commissure anterieure (69,4 ± 1,7°) que l’ostium droit (4,2 ± 0,27 mm et 76,6 ± 1,6°). La coronaire droite etait entre 80° et 100° par rapport a la circonference aortique dans 66 % des cas, alors que la coronaire gauche naissait avec un angle plus aigu ( Conclusion Ce travail permet de definir precisement l’anatomie de la naissance des arteres coronaires ce qui devrait etre utile au chirurgien, au cardiologue et au radiologue.

Objectifs Connaitre les principales indications d’imagerie pour le bilan d’une scoliose en fonction de l’âge de l’enfant : quel examen ? quand ? comment ? Apprendre a reconnaitre les scolioses secondaires et revoir leurs principales etiologies. Proposer une approche transversale pour reconnaitre les sequelles de scoliose a l’âge adulte. Points cles Les deformations rachidiennes les plus frequentes sont les scolioses et les cyphoses. Toutes les modalites d’imagerie sont utilisees a la phase diagnostique, en fonction de l’examen clinique puis au cours de l’evolution, a la recherche de complications essentiellement medullaires. L’evolution a long terme peut etre responsable de deformations severes avec chez l’adulte des sequelles disco-vertebrales, des compressions radiculaires, des lesions medullaires chroniques. Resume Le diagnostic de scoliose chez l’enfant est clinique, mais un bilan et un suivi radiographique regulier sont indispensables pour la surveillance de l’evolutivite. Des radiographies du rachis entier de face et profil de bonne qualite sont necessaires pour evaluer une scoliose. Les indications de scanner et IRM sont le bilan etiologique (surtout scolioses secondaires : infections, tumeurs), des signes neurologiques, le bilan pre-operatoire et l’evaluation des sequelles. Chez l’adulte, les scolioses posent le probleme de sequelles rachidiennes mecaniques (deformation sagittale et frontale, lesions discales et articulaires) source de radiculopathies invalidantes.

Objectifs pedagogiques Connaitre la definition du polytraumatisme. Connaitre le protocole de prise en charge radiologique de ce type de patient. Savoir reconnaitre les principales lesions. Messages a retenir Le polytraumatisme est une pathologie grave et frequente. La prise en charge en imagerie doit etre protocolisee pour etre systematique et rapide. Une radiographie du thorax de face au lit et une echographie thora-cique et abdominale a la recherche d’epanchement doivent etre realisees des l’accueil du patient. En fonction des resultats, un traitement en urgence adapte peut parfois etre indispensable (chirurgical ou radiologique). Si l’etat du patient le permet, un scanner corps entier (incluant des coupes du sommet du crâne au pubis) doit etre realise.

Objectifs Connaitre la frequence le delai d’apparition et les differents types de reactions cutaneo-muqueuses liees a l’injection des produits de contraste iode. Materiels et methodes Entre fevrier et avril 2006, 404 patients ayant eu un examen tomodensitometrique au CHU de Poitiers ont ete inclus au decours de l’examen et contactes par telephone entre 15 et 17 jours apres l’examen, par le meme dermatologue. Les criteres etudies ont ete les antecedents allergiques, la prise eventuelle d’une premedication, le type de produit utilise, les reactions immediates et retardees. Resultats Deux cent trente quatre patients (dont 28 % se declaraient allergiques) ont ete finalement inclus, 170 n’ayant pu etre contactes lors de l’enquete telephonique. Vingt huit ont presente une reaction cutanee (11,9 %) dont 2,1 % precoce et 9,8 % tardive (entre 24 heures et 12 jours, mediane 30h). Les reactions incluaient 6 œdemes de Quincke dont 5 tardifs. Il existait un lien entre la probabilite de faire une reaction et la notion d’allergie de contact ou medicamenteuse. Conclusion les reactions tardives aux produits de contraste iode (gt ; 1 heure) sont plus frequentes que les reactions precoces, dans notre serie. Elles pourraient avoir ete favorisees par la prise d’une premedication anti histaminique.

Objectifs pedagogiques Revoir les criteres « RECIST ». Comprendre comment les appliquer en pratique courante. Savoir resoudre les cas difficiles. Connaitre les specificites des nouveaux traitements anti-angiogeniques pour la surveillance radiologique. Messages a retenir Les criteres RECIST doivent etre employes pour la surveillance des patients en oncologie. Ces criteres doivent etre combines avec l’apparition ou non de nouvelles cibles. Le compte rendu definitif doit contenir l’un des items suivants : reponse complete, reponse partielle, stabilite tumorale, progression tumorale.

Objectifs pedagogiques Rappeler les notions cliniques et biologiques permettant d’evoquer le diagnostic d’AAE. Connaitre les signes scanographiques de l’AAE. Savoir discuter les diagnostics differentiels. Messages a retenir Les pneumopathies d’hypersensibilite (ou alveolites allergiques extrinseques) sont des maladies inflammatoires pulmonaires dues a l’inhalation repetee de contaminants. Sur le scanner, des nodules centro-lobulaires ou des zones de consolidations des bases peuvent etre retrouves dans la forme aigue. Dans la forme subaigue, des nodules aux contours mal definis, du verre depoli et ou une perfusion mosaique sont retrouves. La fibrose est tardive et apparait si l’exposition a l’allergene persiste. Le caractere migratoire dans le temps et l’espace est evocateur du diagnostic.

PurposeIn multiple myeloma, skeletal radiographs are still regarded as the reference imaging examination because they help to establish the stage of the disease according to the Durie-Salmon Staging System. Whole-body MRI using T1 and STIR sequences increases the detection of myeloma lesions. MRI-measured diffusion has demonstrated high sensitivity in terms of detection in oncology. The main objective of this study is to compare conventional radiographic staging with an MRI whole-body diffusion technique (called DWIBS) in detecting bone lesion monoclonal plasma cell pathologies (multiple myeloma, plasma cell leukaemia, plasmacytoma and MGUS).Materials and methodsTwenty-seven patients were included (multiple myeloma: 24; plasma cell leukaemia, MGUS and plasmacytoma: 1 each). All of them had a whole-body MRI diffusion examination (using a DWIBS sequence). Diffusion MRI and conventional radiographs were compared according to the Durie-Salmon Staging System. In case of doubtful lesions, 12 months of monitoring was used as the reference method for the definitive diagnosis.ResultsThe overall concordance rate between the two techniques was 63%. The DWIBS sequence detected a higher number of lesions leading to a higher Durie-Salmon stage in 37% of the patients: one stage I to II, seven stage I to III, and two stage II to III. In 18.5% of the patients, the MRI was positive while the radiographs were normal and these discrepancies were most often located in sites poorly explored by X-ray (spine, pelvis and ribs). In one patient (4%), the MRI provided a stage lower than that of the X-rays (stage II vs. III). In this case, the X-rays were positive at the humerus and femur, unlike the DWIBS sequence. Our per site analysis confirmed the clear superiority of the DWIBS sequence when compared with X-rays in the exploration of the cervical spine (56 vs. 0%, P

Introduction The aim of our study was to analyze medium and long-term results of proximal ulnar osteotomy with and without ligament injury in neglected Monteggia injury in children. Material and methods This retrospective, multicenter study included 28 patients. Clinical criteria concerned the range of motion, pain and MEPI score, and radiologic criteria comprised of Storen line, head-neck ratio, radial neck angle, and signs of osteoarthritic remodeling. Results Twenty-eight patients were reviewed, at a mean 6 years’ follow-up (range, 2–34 y). Sixteen had proximal ulnar osteotomy without ligament reconstruction, and 12 had associated ligamentoplasty. Both groups showed significant clinical and radiological improvement, with no significant difference. Patients operated within less than 1 year had better clinical and radiographic results. There was no correlation between age at surgery and quality of results. The 5 patients who underwent condyloradial pinning showed early recurrence of dislocation and osteoarthritic remodeling. The three cases of Bado type-3 lesion had early recurrence of dislocation. Discussion Proximal ulnar osteotomy gives good long-term results in Bado type-1 lesions, regardless of age, if performed before 1 year, in the absence of osteoarthritic remodeling. Associated ligamentoplasty does not seem to be useful. Level of evidence IV (retrospective).