Distal humerus fractures in patients over 65: Complications

SummaryIntroductionFractures of the distal humerus in patients over the age of 65 remain a therapeutic challenge. Treatment options include conservative treatment, internal fixation or total elbow arthroplasty. The complications of these different treatment options were evaluated in a multicentre study.Materials and methodsFour hundred and ninety-seven medical records were evaluated. A retrospective study was performed in 410 cases: 34 received conservative treatment, 289 internal fixation and 87 underwent total elbow arthroplasty. A prospective study was performed in 87 cases: 22 received conservative treatment, 53 internal fixation, and 12 underwent total elbow arthroplasty. Patients were evaluated after at least 6 months follow-up.ResultsThe rate of complications was 30% in the retrospective study and 29% in the prospective study. The rate of complications in the conservative treatment group was 60%, and the main complication was essentially malunion. The rate of complications was 44% in the internal fixation group and included neuropathies, mechanical failure or wound dehiscence. Although complications only developed in 23% of total elbow arthroplasties, they were often more severe than those following other treatments.DiscussionComplications develop in one out of three patients over 65 with distal humerus fractures. Three main types of complications were identified. Neuropathies especially of the ulnar nerve, especially during arthroplasty, must always be identified, the nerve requiring isolation and transposition. Bone complications, due principally to mechanical failure, were found following internal fixation. Despite technical progress, care must be taken not to favor excessive utilization of this treatment option in complex fractures on fragile bone. Although there were relatively fewer complications with total elbow arthroplasty they were more difficult to treat. Ossifications were frequent whatever the surgical option and can jeopardize the functional outcome.Level of evidenceLevel IV

High weekly integral dose and larger fraction size increase risk of fatigue and worsening of functional outcomes following radiotherapy for localized prostate cancer

IntroductionWe hypothesized that increasing the pelvic integral dose (ID) and a higher dose per fraction correlate with worsening fatigue and functional outcomes in localized prostate cancer (PCa) patients treated with external beam radiotherapy (EBRT). MethodsThe study design was a retrospective analysis of two prospective observational cohorts, REQUITE (development, n=543) and DUE-01 (validation, n=228). Data were available for comorbidities, medication, androgen deprivation therapy, previous surgeries, smoking, age, and body mass index. The ID was calculated as the product of the mean body dose and body volume. The weekly ID accounted for differences in fractionation. The worsening (end of radiotherapy versus baseline) of European Organisation for Research and Treatment of Cancer EORTC) Quality of Life Questionnaire (QLQ)-C30 scores in physical/role/social functioning and fatigue symptom scales were evaluated, and two outcome measures were defined as worsening in >= 2 (WS2) or >= 3 (WS3) scales, respectively. The weekly ID and clinical risk factors were tested in multivariable logistic regression analysis. ResultsIn REQUITE, WS2 was seen in 28% and WS3 in 16% of patients. The median weekly ID was 13.1 L center dot Gy/week [interquartile (IQ) range 10.2-19.3]. The weekly ID, diabetes, the use of intensity-modulated radiotherapy, and the dose per fraction were significantly associated with WS2 [AUC (area under the receiver operating characteristics curve) =0.59; 95% CI 0.55-0.63] and WS3 (AUC=0.60; 95% CI 0.55-0.64). The prevalence of WS2 (15.3%) and WS3 (6.1%) was lower in DUE-01, but the median weekly ID was higher (15.8 L center dot Gy/week; IQ range 13.2-19.3). The model for WS2 was validated with reduced discrimination (AUC=0.52 95% CI 0.47-0.61), The AUC for WS3 was 0.58, ConclusionIncreasing the weekly ID and the dose per fraction lead to the worsening of fatigue and functional outcomes in patients with localized PCa treated with EBRT

Patellar chondropathy prevalence at anterior cruciate ligament reconstruction: analysis of 250 cases.

ERMAInternational audienceINTRODUCTION: Anterior knee instability caused by anterior cruciate ligament (ACL) deficiency results in meniscal as well as chondral femorotibial and/or femoropatellar damages over a more or less long duration delay. This study's objectives were, in chronically deficient ACL patients, to assess onset delay for developing chondral patella lesions and also analyse these lesions characteristics in relation to laxity duration. HYPOTHESIS: Chondral patellar lesions in ACL deficient knees get worse with time. MATERIAL AND METHODS: We reviewed 250 charts of patients who had undergone arthroscopically assisted surgery for knee anterior laxity. The arthroscopic procedures were conducted between January 1995 and January 2005. Chondral damages were evaluated at surgery according both to International Cartilage Repair Society (ICRS) and Bauer and Jackson classifications. The data were analyzed using the Kruskal-Wallis test and the Fisher exact test. RESULTS: Of the 250 analysed charts, 72 patients (28.8%) were found to present chondral patella lesions. The majority of these lesions were superficial and involved the lateral facet area. We observed a statistically significant ICRS worsening grade in relation to laxity duration. DISCUSSION: Few publications in the literature report patellar involvement in anterior laxity of the knee. However, our results are comparable to those of the rare series found. The pathomechanics of these lesions has not yet been precisely identified and requires further biomechanical studies. CONCLUSION: Patellar damage is frequent with anterior laxity (28.8% in our series) and duration is correlated with statistically significant aggravation of these lesions. Currently, the assessment of these patellar lesions is considered less important than meniscal and femorotibial lesions, even though the natural history of ACL disruption seems to be evolving toward degeneration of all the compartments of the knee, including the femoropatellar compartment

Percutaneous fixation of tibial plateau fractures under arthroscopy: a medium term perspective.

ERMAInternational audienceINTRODUCTION: Arthroscopically assisted percutaneous internal fixation has found its place in the treatment of Schatzker I-III tibial plateau fractures, with good short-term results reported. The objective of this study was to observe the progression of osteoarthritis at the medium term through clinical and radiological assessment. PATIENTS AND METHODS: Twenty-seven patients were treated with arthroscopy-assisted percutaneous fixation for stage I-III Schatzker tibial plateau fractures. RESULTS: Twenty-one patients were reviewed with a mean follow-up of 59.5 months (range, 24-138 months); satisfaction was good except for return to sports activity. The mean IKS score was 85.2 for the knee score and 91 for function. The mean Lysholm score was 86 points, with a mean Tegner activity score of 4. A mean score of 25.5 and 8 points was found for the clinical and radiological Rasmussen scores, respectively; 47.6% of the patients presented early osteoarthritis on radiological evaluation. DISCUSSION: The medium-term functional results were comparable to the short-term results. The patients were satisfied except for return to sports activity. Age at surgery appears as a prognostic factor for osteoarthritis. CONCLUSION: Arthroscopic internal fixation remains the technical reference for Schatzker I-III tibial plateau fractures despite the appearance of osteoarthritis, which remains less extensive than in open surgery. LEVEL OF EVIDENCE: Level IV. Retrospective study

Is external rotation the correct immobilisation for acute shoulder dislocation? An MRI study

ERMAInternational audienceINTRODUCTION: Anterior dislocation of the shoulder is frequent, with high rates of recurrence. Immobilization in external rotation (ER) seems to improve results, although few studies have actually demonstrated this. The present MRI study examined the impact of ER on labral and capsular ligamentous complex lesions after primary dislocation. MATERIAL: A prospective study was started up on January 1st, 2007. Inclusion criteria were: acute initial anteromedial dislocation of the shoulder, without past history of shoulder trauma. There were 23 such patients, with a mean age of 37 years. METHODS: Early MRI scan used the following protocol: one acquisition in internal rotation followed by one in ER. Study criteria were: hemarthrosis, ER amplitude, rotator cuff status, bone lesion, and labral lesion stage (Habermeyer's classification) and displacement (Itoi criteria). RESULTS: There were 12 right and 11 left shoulders. Mean time to MRI was 3.7 days. There were three rotator cuff tears, no glenal lesions, and 14 humeral notches. Hemarthrosis was almost systematically present, with its distribution modified by ER in 75% of cases; three patients showed no posterior hemarthrosis, in whatever rotation. Mean ER was 37 degrees. On Habermeyer's classification, there were 12 stage-1 lesions, and 10 stage-2; one patient had no labral lesion. All separated labra were reduced in ER, five (21%) totally. In six cases, labral displacement changed according to rotation. All anterior joint effusion was reduced in ER, in three cases totally. DISCUSSION: According to Itoi among others, immobilization in ER is the way to reduce recurrence of anterior dislocation. The present study confirmed that labral reduction was systematic with ER, but it was by no means always complete. ER seemed more effective in reducing the separation. Results further confirmed that ER reduced anterior capsule volume, a recurrence factor. CONCLUSION: ER reduced hemarthrosis, anterior capsule detachment and labral lesions, and never the contrary. The interest of immobilization in ER to prevent shoulder instability needs confirming by long-term clinical studies; we are therefore extending the present MRI study by a clinical study of ER immobilization in all patients showing significant labral lesion reduction. LEVEL OF EVIDENCE: Level IV. Retrospective therapeutic study

Radiothérapie des cancers de vessie

International audienceSurgery (radical cystectomy) is the standard treatment of muscle-invasive bladder cancer. Radiochemotherapy has risen as an alternative treatment option to surgery as part as organ-sparing combined modality treatment or for patients unfit for surgery. Radiochemotherapy achieves 5-year bladder intact survival of 40 to 65% and 5-year overall survival of 40 to 50% with excellent quality of life. This article introduces the French recommendations for radiotherapy of bladder cancer: indications, exams, technique, dosimetry, delivery and image guidance

ANOCEF Consensus Guideline on Target Volume Delineation for Meningiomas Radiotherapy

Purpose/Objective(s)Meningiomas are the most common primary intracranial tumor. They are developed at the expense of the dura, with an overall incidence which has increased over the past decade. To date, there is no published specific guideline about meningiomas target volume. No prospective study has defined a consensus for delineation in meningiomas’ radiotherapy. Therefore, target volume definition is mainly based on retrospective studies, with a heterogeneous population of patients. The aim of this paper is to describe delineation guidelines for meningiomas’ radiotherapy as an adjuvant or definitive treatment with Intensity Modulated Radiation Therapy (IMRT) and stereotactic radiation therapy (SRT) techniques.Materials/MethodsThis guideline is based on a consensus endorsed by a global multidisciplinary group of brain tumor experts’ member of the ANOCEF (French neuro-oncology association). A two round modified Delphi consensus was achieved, and the consensus was adopted by the RAND/UCLA method. The third round was carried out in videoconference, in order to allow experts to debate and argue on remaining uncertain proposals.ResultsTwenty experts from 17 radiotherapy center participated. After 3 rounds, all the proposals resulted in a consensus. The ANOCEF guideline committee proposed to perform an unenhanced planning CT scan, merged with a post-contrast MRI obtained at the time of radiotherapy and preoperative MRI in case of adjuvant treatment. GTV is defined by T1 contrast-enhancing lesion, thickened meninges, and directly invaded bone. For IMRT, the CTV include: Grade I: No margin around the GTV. Grade II: Margin of 5mm to expand GTV in normal brain tissue, hyperostosis, along the unthickened meninges and venous sinuses if the GTV is coming into contact. Grade III: Margin of 10mm to expand GTV in normal brain tissue, hyperostosis, along the unthickened meninges, and optic or cranial nerves in contact with GTV. In case of bone invasion, a margin of 5 or 10mm in the healthy bone around the GTV is recommended, for grade II or III respectively. Otherwise, it is considered as an anatomical barrier and does not need to be included in the target volume. In case of post-operative radiotherapy, no additional margin is required for CTV for grade I around tumor bed. A 5 and 10mm margin is required for grade II and III. The cranial flap should only be included in the CTV only over 5 or 10mm for grades II or III, in case of initially invaded bone. The drill holes and osteotomy areas should be included if they come into contact with target volume. SRT is not recommended for grades II and III, excluding relapse situation. CTV corresponds to GTV without additional margin.ConclusionThe current consensus provides a detailed delineation guideline for meningioma, suggesting smaller margins than the major studies published to date

Angiotensin II receptor blockers, steroids and radiotherapy in glioblastoma—a randomised multicentre trial (ASTER trial). An ANOCEF study

International audienceBackgroundGlioblastomas (GBMs) induce a peritumoural vasogenic oedema impairing functional status and quality of life. Steroids reduce brain tumour–related oedema but are associated with numerous side-effects. It was reported in a retrospective series that angiotensin receptor blockers might be associated with reduced peritumoural oedema. The ASTER study is a randomised, placebo-controlled trial to assess whether or not the addition of Losartan to standard of care (SOC) can reduce steroid requirement during radiotherapy (RT) in patients with newly diagnosed GBM.Patients and methodsPatients with a histologically confirmed GBM after biopsy or partial surgical resection were randomised between Losartan or placebo in addition to SOC with RT and temozolomide (TMZ). The primary objective was to investigate the steroid dosage required to control brain oedema on the last day of RT in each arm. The secondary outcomes were steroids dosage 1 month after the end of RT, assessment of cerebral oedema on magnetic resonance imaging, tolerance and survival.ResultsSeventy-five patients were randomly assigned to receive Losartan (37 patients) or placebo (38 patients). No difference in the steroid dosage required to control brain oedema on the last day of RT, or one month after completion of RT, was seen between both arms. The incidence of adverse events was similar in both arms. Median overall survival was similar in both arms.ConclusionsLosartan, although well tolerated, does not reduce the steroid requirement in newly diagnosed GBM patients treated with concomitant RT and TMZ