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Glomous tumors are rare and benign, generally affecting the fingers. Other localizations have nevertheless been described. We report the case of a patient who presented a supra-patellar glomous tumor provoking a pain-induced limp. Magnetic resonance imaging confirmed the diagnosis. The patient underwent complete surgical resection of the tumor followed by total resolution of the pain. Glomous tumors in an atypical localization may go unnoticed, with the risk of late or erroneous diagnosis. Symptoms are easily resolved with simple resection.

Purpose To assess health-related quality of life (HRQOL) following rehabilitation of amputees suffering symmetric peripheral gangrene (SPG) after septic shock. Material and methods A retrospective cohort study was conducted in nine French specialized rehabilitation centers. Thirty-two ICU adult patients hospitalized between 2005 and 2015 for septic shock who additionally presented with SPG resulting in at least two major amputations were enrolled. HRQOL was assessed by EQ-5D-3 L questionnaire. Results All patients (mean ICU length of stay 39 ± 22d, SAPS II 58 ± 18) had both lower limbs amputated and 84% were quadruple amputees. HRQOL, assessed 4.8 ± 2.8 years after amputation, was inferior to the French reference. However, patients' self-rated health status was similar to the reference at the time of HRQOL assessment. The main factor of impaired HRQOL was intense phantom pain, not the mobility or self-care dimensions of EQ-5D. All patients except one preferred to be treated again for SPG despite disability. Conclusion ICU survivors referred to rehabilitation centers after SPG-related amputations had impaired HRQOL. At the time of HRQOL assessment, they considered themselves in good health and preferred to be treated again despite disability. Appraisal of long-term functional outcome should not be used to guide end-of-life decision-making in this situation.

The original article [1] contained an error whereby the captions to Fig. 3 and Fig. 8 were mistakenly interchanged.

Lorsqu’un militaire francais est blesse dans une zone de conflit, une chaine de soutien medicochirurgical est deployee; d’abord avec les mesures d’urgence (role 1), puis avec le traitement chirurgical (roles 2 et 3); enfin, le soldat est rapatrie vers un hopital militaire sur le sol francais (role 4). La medecine physique et de readaptation (MPR) est le dernier maillon de la chaine de soutien medical et le premier maillon de la reinsertion sociale et professionnelle. L’equipe de MPR, le militaire et sa famille travaillent ensemble pour offrir au militaire les meilleures chances de recuperation et de retour a l’emploi au sein des forces.

Contexte Les recents conflits armes (Afghanistan) ont vu reapparaitre mines antipersonnel et agents explosifs improvises, responsables de lesions traumatiques complexes a haute energie associant polyfracas de membres et blast.

L’armee francaise a subi depuis 2004 une intensification de ses combats en operations exterieures et le nombre de blesses a prendre en charge a augmente. Leur reinsertion sociale et professionnelle reste encore a ce jour mal evaluee. Nous avons etudie le devenir socioprofessionnel et la qualite de vie des 49 blesses de guerre militaires francais hospitalises dans le service de medecine physique et de readaptation de l’hopital d’instruction des Armees Percy entre 2004 et 2010. Cette etude a permis d’objectiver les difficultes et permettra de mettre en oeuvre des mesures pour ameliorer cette reinsertion. Il s’agit ici d’une etude realisee precocement, il serait interessant de reevaluer ces patients a long terme.

Les ossifications heterotopiques sont devenues des complications frequentes des amputations traumatiques de guerre en raison de la multiplication des blessures par explosion dans les conflits les plus recents. Les facteurs de risque principaux de leur survenue sont le blast et l’amputation en zone blessee. Le traitement medical doit etre privilegie. Leur physiopathologie n’est pas encore elucidee mais il semblerait qu’une cascade d’evenements biochimiques inflammatoires mene a leur formation.

Le traumatisme crânien leger est frequent dans la population militaire engagee sur les theâtres d’operations exterieures. Il est souvent du au blast lors d’explosions. La complexite de son evaluation et de sa prise en charge est liee a l’intrication de troubles secondaires ou associes (syndrome post-commotionnel, etat de stress post-traumatique et depression) avec qui il partage divers symptomes. Cette revue de la litterature, axee sur les specificites militaires, tente de preciser les liens entre ces tableaux.

Afin d’optimiser la récupération, l’autonomie et la réinsertion professionnelle des blessés militaires français victimes d’amputation traumatique, un appareillage technique de qualité est nécessaire. Les genoux à microprocesseur disponibles et remboursés restaurent en partie les capacités fonctionnelles du patient. Cependant les genoux dits de nouvelle génération, dotés d’une intelligence artificielle, permettent une marche quasi physiologique, efficace et sécurisante, et des activités supérieures de marche (descente et montée des escaliers, pentes, marche en terrains irréguliers, marche arrière, piétinement) performantes. C’est devant cet enjeu médico-technique que les instances médico-militaires, conscientes du bénéfice à apporter aux militaires, ont validé leur prise en charge financière. Elle s’applique sous conditions strictes, au profit des militaires blessés en opération ou en service, qui s’inscrivent dans un parcours de réinsertion professionnelle et dont le besoin et l’amélioration ont été préalablement validés par le service de santé des armées.

Resume But Determiner les performances diagnostiques et l’acceptabilite d’une methode non invasive de l’evaluation de l’obstruction sous-vesicale, le penile cuff-test (PCT), comparativement a l’etude pression-debit (EPD), methode de reference. Materiel Etude prospective monocentrique comparant les categories « obstrue », « non obstrue » ou « equivoque » tirees des EPD et des PCT, chez 30 patients presentant des symptomes du bas appareil urinaire. Pour le cuff-test , un brassard place autour du penis se gonfle automatiquement lors de la miction jusqu’a interrompre le jet urinaire. La pression du brassard necessaire a l’interruption du debit reflete la pression vesicale isovolumetrique. Pour l’interpretation, la pression d’interruption maximale et le debit maximum sont automatiquement reportes sur un nomogramme specifique. Resultats Les EPD ont classe 11 patients (39 %) dans la categorie obstruee, six patients (22 %) dans la categorie non obstruee et 11 patients (39 %) dans la categorie equivoque. Dans 61 % de cas, le patient etait classe dans la meme categorie par les deux examens. La valeur predictive positive « obstrue » du cuff-test etait de 82 % et la valeur predictive negative « non obstrue-equivoque » etait de 88 %. La mediane de l’echelle visuelle analogique penibilite etait inferieure pour le cuff-test a 1/10 (0–3) vs 5/10 (2–10) pour l’EPD, et ce maniere statistiquement significative ( p = 0,004). Conclusion Le cuff-test apparaissait etre une technique alternative credible a l’etude pression debit formelle. Ses valeurs predictives etaient bonnes et sa tolerance meilleure.

Resume But Evaluer le debit de vidange des catheters d’autosondage. Materiel Etude experimentale comparant in vitro, par mesures debitmetriques repetees, les debits moyens de drainage des differents catheters d’autosondage les plus utilises en France, en fonction de leur charriere (Ch10, 12 et 14 pour la femme ; Ch12, 14 et 16 pour l’homme). Resultats L’augmentation de charriere etait significativement associee a une augmentation du debit moyen. Pour les catheters destines aux femmes, le debit moyen variait de 2,83 a 3,7 mL/s pour les sondes Ch10, de 4,31 a 5,35 mL/s pour les sondes Ch12 et de 7,00 a 7,85 mL/s pour les sondes Ch14 ( p p Conclusion Cette etude experimentale a observe que l’augmentation de charriere etait significativement associee a une augmentation du debit moyen, ce qui pourrait aider le clinicien a adapter le materiel prescrit pour l’autosondage selon les besoins des patient(e)s.

Objective Even if properly fitted, the posture and gait of amputee people are disturbed, leading to compensations and over-solicitations of the contralateral limb. The recent commercialization of new generation ankle-foot (NG) prosthesis is not covered by French social security insurance. The evaluation of the service delivered by these medical devices was until now a combination of multidisciplinary evaluations and patient assessments, but needs objective evaluation. Several teams reported a benefit of NG feet, mainly in terms of joint mobility, walking speed and reduction in compensations. But the main subjective improvement is in balance, both in static (more comfortable waiting position) as well as in dynamic (quality and fluidity of walking), which was poorly evaluated in amputees with NG feet. The main objective of this research is to evaluate the relevance of these NG feet in terms of static stability, on both flat and inclined surfaces. Material/patients and methods Six transtibial subjects were included. Three NG feet (Elan®, Propriofoot®, Meridium®) and the patient's usual foot were successively tested. For each foot type, after socket and alignment validation by an expert prosthetist, an acclimatization period of 15 days at home was observed. After this period, clinical, instrumental (static acquisitions of 20 s on two force platforms, eyes open and closed, on flat ground and on 12% inclined slope uphill and downhill) and functional evaluations (Berg Balance Scale and Activity Specific Balance Scale) were performed. Participants observed a wash out period of 3 weeks with the usual foot before testing each NG foot. The static parameters collected were: lower limb joint angles, Center of Pressure (COP) variation, ground reaction forces (GRF), and functional scores. Results In static position, a larger prosthetic ankle dorsiflexion, less compensations of the amputed lower limb, better symmetry of the GRF and increase of CoP parameters (as length of trajectory and range) were found with NG feet, compared to ESR. Discussion, conclusion The absence of postural control leads to asymmetrical posture, leading to osteoarticular complications. Ankle mobility of NG feet may allow a better balance and improve destabilizations adaptations, above all on slope, and may reduce sound limb compensations.

Introduction/Background Despite technological advances upper limb prosthesis, myoelectric control requires a long learning process. The absence of sensory feedback is very likely to impinge the appropriation of the prosthesis. We explored a sensory substitution alternative with various configurations and settings for vibrotactile feedback and myoelectric parameters. Material and method Six vibrators were placed on a line or circumferentially around the arm. Space intervals between vibrators were absolute (2 cm) or proportional to the length or the circumference of the arm. Dispositions as longitudinal proportional and absolute, circular proportional and absolute were tested. Sixty, 100 and 140 ms of duration and intensities of 62.5; 100; and 167 mA were explored. Estimate location of the vibration, and perceived intensity between 0 (no feeling) to 3 (strong) were assessed. EMGs from biceps and triceps were recorded during isometric contraction to control the elbow velocity of an avatar displayed on a screen. EMGs were filtered and normalized from maximal contraction. A threshold of minimum muscle activity and a gain of the velocity control were adjusted to allow fast an intuitive control. Results The circular proportional disposition elicited better discrimination results than the 3 others dispositions (P A threshold between 5 and 7.5% of the maximum force, and a velocity gain varying from 0.3 to 1.2 rad.s-1 for a change in muscle contraction of 10% MVC were found to enable precise control of the avatar. Conclusion The circular proportional disposition of the vibrator is a well suited configuration for sensory substitution. Our next step will be to combine sensory feedback given by vibrator to the myoelectric control. This sensory substitution could improve prosthesis control, and may attenuate phantom limb pain.

Introduction/Background This study aims to describe the spinopelvic sagittal alignment in transfemoral amputees (TFAs) and to compare with a reference population. To our knowledge, this is the first recent radiologic study of the TFAs’ spine and the first postural approach destined to better understand the high prevalence of low back pain (LBP) in the TFAs. Material and method Volunteers with transfemoral amputation underwent bi-planar X-rays with 3-D reconstructions of the spine and pelvis. Sagittal parameters were analyzed in the light of literature and compared to those of a reference group of non-amputees. Differences between TFAs with and without LBP were also searched. Results Twelve subjects have been prospectively included. The two groups (TFA-LBP n = 5 and TFANoP n = 7) were comparable in terms of gender, age, amputation delay and sedentarity. In the TFALBP group, the impact of LBP was estimated on average to 16.4% with the ODI (SD 7.9%, [6; 24]). Pelvic incidences were within normal limits, except for one subject of the TFA-LPB group. Anterior pelvic tilt was observed in two subjects of each group. Eight subjects (6 NoP and 2 LBP) had abnormal low value of TK. The mean angle of TK in the TFA-NoP group was lower than in the TFA-NoP group (P = 0.0511). Two subjects of the TFA-LBP group had a hyperlordosis while all the TFAs-NoP had a lower lumbar lordosis than expected in an economic posture. Concerning the sagittal balance, four of the five individuals of the TFA-LBP group had unbalanced sagittal posture versus two of the seven in TFAs-NoP. Conclusion This study emphasizes the importance of considering the sagittal balance of patients with a transfemoral amputation to prevent and manage the onset of low back pain. Moreover, in this population, it seems necessary to study not only the sagittal plane but also the frontal plane, which is also probably unbalanced.

Introduction/Background Stump pain is usually hard to cure. This pain is often beyond the efficiency of painkillers, so hard that some patients threaten to commit suicide in order to end it. We analyzed our experience of the efficiency of acupuncture for painful amputees suffering from their stumps. Material and method Retrospective analysis of acupuncture sessions performed on painful amputees referred to our center for intractable pain. Pain was evaluated with Visual Analog Scale, before and after acupuncture sessions. We used a various number of needles per patient (1 to 10) and depth of puncture varies from 1 mm to few centimeters. The average duration of the acupuncture sessions was 30 minutes. Stumps were carefully analyzed in order to puncture the acupuncture needles in the damaged tissues (painful neuroma, muscular trigger point, painful scar) and in classical acupuncture points. The needles were carefully places to avoid the pain caused by a too fast and too deep puncture. Results Fifty painful amputees (34 men and 16 women) were included in our study. The cause of amputation was traumatic (n = 45), arteritic (n = 2), septic shock (n = 2), tumoral (n = 2). The level of amputation was transtibial (n = 26), transfemoral (n = 14), hands (n = 3), forearms (n = 2), arms (n = 2), disarticulation of shoulder (n = 2), foot (n = 1). These intractable pains were relieved by successive acupuncture session in 80% of patients; among those, the mean VAS improved from 9 to 3/10. Conclusion Acupuncture seems to be particularly efficient for pathologic neuromas pains as for causalgias, muscles trigger points and algo-hallucinosis. After some sessions, acupuncture may alleviate for months or years the neuroma pain. Acupuncture is a cheap, easy and efficient antalgic therapy for neuroma pains, causalgias, muscular triggers points and algo-hallucinosis of amputated stumps. Further studies are needed to determine the best modalities of this therapy.

Introduction/Background Since ancient civilizations, health through sports is a fundamental military rule. Bonaparte first integrates by law sports education in military schools. After word war I and II, a collective awareness has emerged, often under the impulse of mutilated warriors. Then, military sport then became a strong tool of peace among nations, and the awareness of this lever led to the creation of the CISM (International Military Sports Council) in 1948. Material and method France has developed a strong link between each steps of military sports management. The aim of this presentation is to sum up the military PMR French departments organisation and missions. Its strong links with the military forces, including Navy and Air forces, has strengthened since the recent conflicts in Afghanistan, Middle East and terrorists attacks. Since the use of Improvised Explosive Devices, major limb injuries and traumatic amputations have emerged. The multidisciplinary approach of Percy Military hospital, is now highlighting a category of high-level expectations young wounded soldiers, whose aim is to go back to duty, and to get back to their former sporty way of life. Results Since 2001, a French multidisciplinary process is improving, including military PMR, psychiatry practitioners, social workers, and headquarters, leading to the creation of wounded aid cells, and reconstruction courses by adapted sports. The global reflection around the recovery of a sport with a residual disability is a fundamental mission of PMR military departments. Thanks to the implementation of financial means, (including possibility of purchasing electronical high technologies prostheses), there is now a high lightening of these wounded soldiers, through local and international events like Invictus games or Ad victoriam. Conclusion Thanks to the multidisciplinary approach of the wounded soldier, and the inclusion of adapted sport has a way of life, the glimpse at these soldiers is changing, in French armed forces but also in French population.

Objective Symmetric peripheral gangrene (SPG) is a rare but severe complication of septic shock often leading to multiple amputations. Epidemiology of SPG and long-term outcome remain poorly known. Amputations are serious offense to body but can benefit from rehabilitation and prosthesis. Our objectives were to describe epidemiology of SPG and to assess health-related quality of life (HRQOL) once rehabilitation was achieved. Material/patients and methods A prospective and retrospective, multicentric study was performed. Adult patients hospitalised between 2005 and 2015 were included. They must have undergone at least two amputations (whatever the level) and have been discharged in a specialized rehabilitation Department. HRQOL was assessed with generic scale EQ-5D-3L by phone call. Epidemiologic data were extracted from medical letters. Results Nine centres on 13 participated, 32 patients were recruited and medical letters were available for 27 of them. SPG was observed in a majority of female (59%), aged around 53 yo. Mean intensive care unit (ICU) length of stay was 39 (±22) days. Infectious agents were in majority Gram positive or negative cocci (68%), but Escherichia Coli took an important part (17%). All patients were amputated of the two lower limbs and 84% were quadruple amputees. HRQOL estimated with EQ index was inferior to the French reference. However, patients rated themselves their health state as similar to the reference and superior to the reference before SPG. Intense pain due to phantom pain was the main factor of impaired EQ index. Painkillers use was statistically dependant of antidepressants use. All patient, except one, said they would be willing to be treated again for SPG. Discussion, conclusion SPG is mainly due to Gram positive or negative cocci but also Escherichia Coli and leads to severe amputations with impaired HRQOL. This is in line with the literature. However, patients report being in good health, but in excellent health before SPG. Such important decrease after sudden critical illness was observed in major trauma. A better analgesic strategy may improve HRQOL. Nevertheless, patients would be willing to be treated again. This should be taken into account before withdrawing life-sustaining therapies.

To assess the diagnostic performances and the acceptability of the penile cuff test (PCT) which is a non invasive method for the evaluation of bladder outlet obstruction (BOO), in comparison with the pressure flow study (PFS), the actual gold-standard.Monocentric prospective study comparing the following subsets: "obstructed", "not obstructed" or "equivocal", deduced from PFS vs PCT, in 30 consecutive patients presenting with lower urinary tract symptoms. For the PCT, a cuff placed around the penis inflated automatically during the micturition, until flow rate interruption. The interruption cuff pressure revealed the isovolumetric bladder pressure (Pcuff-int). The data collected - Pcuff-int and maximum flow rate - were automatically reported on ICS modified nomogram.With the PFS, 11 patients (39%) were classified "obstructed", six patients (22%) "non-obstructed" and 11 patients (39%) "equivocal". In 61% cases, the patient was classified in the same category by both techniques. The "obstructed positive predictive value" of the PCT was 82% and the "non-obstructed-equivocal negative predictive value" was 88%. The median acceptability visual analogic scale score was 1/10 (0-3) for the PCT whereas it was 5/10 (2-10) for the PFS. This difference was statistically significant (p=0.004).The PCT was a reliable non-invasive tool for the diagnosis of BOO in male, in comparison with PFS. The predictive values of the PCT were relevant and its tolerance was better than PFS.

To assess the flow rate obtained by catheters used in self intermittent catheterization.In vitro comparative study designed to compare the average flow rate obtained by intravesical catheters, by repeated flowmetric measures. The catheters studied were the most used in France in Fr10, 12 and 14 for female catheters and in Fr12, 14 and 16 for male catheters.We observed a strict relationship between Charriere and flow rate, both in female and male catheters These results were statistically significant (P0.05). For female catheters, the average flow rate varied from 2.83 to 3.7 mL/s for Fr10 catheters, from 4.31 to 5.35 mL/s for Fr12 catheters and from 7.00 to 7.85 mL/s for Fr14 catheters (P0.05). For male catheters, the average flow rate varied from 4.53 to 5.00 mL/s for Fr12 catheters, from 6.95 to 8.17 mL/s for Fr14 catheters and from 10.4 to 11.07 mL/s for Fr16 catheters (P0.05). In female and male population, despite the observed flow rate differences between catheters, there were no statistically significant differences.This study demonstrated a better flow rate when Charriere increases. Thus, an objective adaptation of self catheterization's materiel is possible when the patient wishes to improve flow rate in order to reduce self intermittent catheterization duration.