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Resume Introduction La nephropathie, induite par les produits de contraste (NIPC), est une complication frequente et grave en milieu de cardiologie interventionnelle. Objectif Le but de notre etude etait de comparer l’incidence de NIPC selon deux protocoles d’hydratation acceleres : le premier par du serum bicarbonate seul et le deuxieme associant le serum bicarbonate a la vitamine C orale. Methodes Il s’agit d’une etude multicentrique prospective, randomisee menee entre octobre 2012 et mai 2013, incluant 160 patients. Resultats L’âge moyen de notre population d’etude etait de 60,8 ± 9,3 ans (36 a 83 ans). Les deux groupes de l’etude etaient comparables a l’etat de base en termes de facteurs de risques cardiovasculaires, de la medication concomitante, et du taux de creatinemie basale. La NIPC etait estimee a 6,3 % dans le groupe vitamine C et a 10 % dans le groupe temoin, avec une difference non significative ( p = 0,38). L’analyse de sous-groupes selon le protocole utilise n’a pas montre de difference significative quant a l’incidence de NIPC. Cependant, une forte tendance a un moindre taux de NIPC a ete notee dans le sous-groupe vitamine C en cas d’utilisation de dose toxique de produit de contraste. De meme, aucune NIPC n’a ete notee dans le sous-groupe de patients âges de plus de 75 ans sous vitamine C. Conclusion Selon notre etude, l’acide ascorbique administre par voie orale dans le cadre d’un protocole de rehydratation accelere ne permet pas de reduire l’incidence de NIPC.

Introduction Arthrogryposis is a condition existing at birth, seen in different diseases that have in common the existence of multiple joint stiffness. The clinical presentation is diversified and the functional prognosis depends on the etiology, which makes therapeutic options different from one case to another. The objective of this study was to describe clinical manifestations observed in arthrogrypotic patients and show the different therapeutic methods and functional results. Methods This was a retrospective study over a period of 12 years from 2000 to 2012, based on clinical examinations of 23 patients with arthrogryposis. Results The mean age of the patients was 6.6 years. The four limbs were involved in 19 cases and only the lower limbs in four cases. The etiology was amyoplasia in nine patients, distal arthrogryposis in three, peripheral neuropathy in two, and muscular atrophy in one infantile patient. Foot deformities were observed in 22 cases, with 25 talipes equinovarus deformities (clubfoot), six convex feet, and five valgus feet. The Ponseti method was applied in 12 clubfeet with recurrence in eight cases. The other clubfeet had functional treatment and necessitated surgical release in 11 cases. Deformation of the knee was seen in 15 patients, flessum in 16 knees, restriction of flexion in eight cases, genu recurvatum in three, stiffness in extension in two, and agenesis of the patella in one case. Surgical treatment was carried out in only one case. Other cases of deformity of the knee were treated by rehabilitation with slight improvement. Deformation of the hip was seen in 15 patients, with 16 hips dislocated and four hips in flessum. The dislocation of the hip was treated orthopaedically in two cases and surgically in six cases, with reduction in all cases but persistence of stiffness. Involvement of the shoulders was observed in eight cases, the elbow in seven cases, the wrist in ten cases, and the fingers in 16 cases. The treatment was based on physical therapy and orthotics in all cases, and improvement was better in the wrist and fingers. Conclusion Arthrogryposis has different clinical presentations. Successful treatment is not constant. Multidisciplinary care is necessary and should be early and continued in order to gain the maximum autonomy and facilitate patients' social integration.

Introduction La periostite est une inflammation a caractere degeneratif affectant le perioste. Sa localisation au niveau du tibia est de loin la plus frequente. La survenue de cette pathologie provient directement d’une tension excessive des insertions musculaires et aponevrotiques fixees au perioste ou d’un grand nombre de chocs repetes. Elle pourrait mimer dans certains cas une pathologie tumorale. Observation Nous rapportons le cas d’une patiente de 40 ans, agricultrice, qui consulte pour douleur chronique de la jambe, d’allure mecanique. A la radiographie on note une lesion hypercondensante du tibia gauche. Le scanner a montre une lesion condensante de la corticale, avec reaction periostee dense en poils de brosse d’allure agressive. Une biopsie chirurgicale a montre un tissu osseux sain. Une scintigraphie osseuse a montre un aspect en faveur d’une fracture de fatigue. Discussion et conclusion La periostite est une inflammation du perioste souvent decrite chez les sportifs mais, dans notre cas, elle est survenue chez une femme pratiquant un travail physique intense pendant de longues heures. L’imagerie peut presenter des lesions condensantes avec une reaction periostee guidant le diagnostic vers d’autres etiologies plus agressives. La scintigraphie osseuse est le gold standard pour la confirmation du diagnostic. La prise en charge therapeutique est simple, consistant en la prescription d’un traitement antalgique avec un repos et arret de l’activite en cause.

Le syndrome du tunnel tarsien est une pathologie rare. Sa symptomatologie comporte des douleurs plantaires et des dysesthesies dans le territoire du nerf tibial posterieur. L’existence d’un Tinel sur le trajet du nerf tibial posterieur est le meilleur argument clinique en faveur de la compression. L’exploration electrophysiologique confirme le diagnostic. L’imagerie permet d’aider l’enquete etiologique a la recherche d’une lesion de la trame osseuse, des sequelles de fracture de l’arriere-pied, des troubles statiques du pied et de la presence d’eventuelles lesions expansives intracanalaires. Le traitement initial est toujours medical, il associe la prescription d’antalgiques, d’anti-inflammatoires. La reeducation sensitivomotrice est toujours indiquee. L’appareillage est indique en cas de troubles statiques du pied. La chirurgie est indiquee en cas d’echec du traitement conservateur ou en presence d’une lesion compressive intracanalaire. Elle est basee sur l’incision du retinaculum des flechisseurs, l’ouverture de l’aponevrose de l’abducteur de l’hallux et la neurolyse du nerf tibial posterieur. Le geste chirurgical doit liberer toutes ces structures pour avoir de bons resultats et eviter les recidives a long terme.

Contrast-induced nephropathy (CIN) is a common and severe complication in interventional cardiology.The aim of our study was to compare the incidence of contrast-induced nephropathy in two accelerated hydration protocols: the first one by the serum bicarbonate and the second combining the serum bicarbonate and oral vitamin C.This is a multicenter prospective, randomized study conducted between October 2012 and May 2013, including 160 patients.The mean age of our study population was 60.8±9.3 years (36-83 years). The two study groups were comparable in terms of cardiovascular risk factors, concomitant medication, and baseline serum creatinine. The CIN incidence was 6.3% in the vitamin C group and 10% in the control group (P=0.38). No significant difference was observed in terms of CIN incidence between the different subgroups analyzed.According to our study, ascorbic acid administered orally as part of an accelerated hydration protocol does not reduce the incidence of CIN.

Resume L’objectif de notre etude etait d’estimer le type et la frequence des erreurs de medication lors des etapes allant de la preparation a l’administration des medicaments injectables. Materiel et methodes Etude prospective dans le service de chirurgie orthopedique par observation directe des pratiques de preparation et d’administration des medicaments injectables. Les erreurs ont ete detectees par comparaison des pratiques observees avec la prescription et le resume des caracteristiques du produit. Resultats Cent preparations et administrations ont ete observees. 241 erreurs affectant les etapes de reconstitution et d’administration ont ete relevees. Leur repartition etait la suivante : non-respect des regles d’asepsie (100 %), erreur de solvant (35 %), probleme de debit de perfusion (64 %), de mode d’administration (36 %) et de dose administree (6 %). Conclusion Cette etude montre que la preparation et l’administration des medicaments injectables constituent des activites a risque pour le patient. Elle suggere egalement la necessite d’une collaboration etroite avec le pharmacien afin d’organiser une formation pour les infirmiers et de rediger des procedures de fabrication standardisees.

Resume La dysplasie ou dysostose cleido-crânienne se traduit par des anomalies dentaires, des anomalies des os ayant une ossification membraneuse (clavicules, crâne, face, bassin) et a un degre moindre du rachis et du reste du squelette. A partir de 2 observations, nous rapportons les differentes manifestations cliniques de cette affection et les problemes orthopediques qu’elle peut poser. Les manifestations cliniques sont tres variables et inconstantes, d’ou la diversite des circonstances de decouverte. Les anomalies claviculaires, faciales et les anomalies d’ossification du bassin sont les plus frequentes et peuvent etre considerees comme des signes majeurs. Ces atteintes ne necessitent pas de traitement dans la majorite des cas. Les anomalies dentaires, la coxa vara et la scoliose necessitent une surveillance reguliere et un traitement en cas d’aggravation progressive. La penetrance incomplete de cette maladie autosomique dominante et sa bonne tolerance expliquent la frequence des formes d’expression clinique discrete ou non diagnostiquees.

Resume La granulomatose septique chronique (GSC) est un deficit immunitaire primitif d’origine genetique, consecutif a un defaut du metabolisme oxydatif des phagocytes. Elle se caracterise par des infections bacteriennes et fongiques repetees. Nous rapportons le cas d’un nourrisson de deux mois hospitalise pour une osteomyelite a Serratia marcescens d’un metacarpien ayant revele une GSC. Bien que rare, la GSC doit etre evoquee en cas d’infection inhabituelle ou atypique.

SummaryBone hydatid disease is a rare pathology, characterized by its long clinical latency, the absence of radiological specificity as well as its challenging surgical treatment. We report an observation of pelvic bone hydatidosis in a 28-year-old patient, appearing with pain and stiffness of the hip as well as a degenerative aspect on the coxofemoral joint on X-ray. The treatment consisted of an extensive hemipelvectomy with femoropelvic arthrodesis, completed by medical treatment. The functional result was excellent in spite of a break in the fixation material, which allowed a certain mobility at the proximal end of the femur. Hydatid disease of bone is infiltrating, diffuse, slow, and progressive, all characteristics explaining the often-delayed diagnosis. Medical imaging provides accurate analysis for planning a broad surgical resection. The quality of surgical resection is determined according to the risk of recurrence. Pelvic locations are particularly difficult to treat. After an enlarged and difficult surgical resection, reconstruction remains aleatory and poses many technical problems.

Resume Introduction La technique habituelle du bloc sciatique par voie parasacree parait une approche facile a realiser, cependant, la tuberosite ischiatique parait difficile a palper. Type d’etude Etude anatomique et clinique dont l’objectif etait de proposer des nouveaux reperes de surface simples de la voie parasacree du nerf sciatique. Patients et methodes Trois dissections sur cadavre frais, effectuees au prealable, ont montre que nos reperes de surface paraissaient exacts et que l’innocuite de cette approche semblait etre confirmee. Vingt patients consentants, ASA I a III, devant beneficier d’une chirurgie du membre inferieur, ont ete inclus dans cette etude prospective. Les blocs realises etaient a visee anesthesique. Le patient etait en position de Sim, une droite etait tracee entre l’epine iliaque anterosuperieure (EIAS) et l’hiatus sacre (HS), une seconde droite passant par l’epine iliaque posterosuperieure (EIPS) etait abaissee, perpendiculairement a la premiere. Le point de ponction (P) utilise etait materialise par l’intersection de ces deux droites. Au point P, l’aiguille etait introduite perpendiculairement a la peau, 20 ml d’un melange de Xylocaine® 2 % et bupivacaine 0,5 % etaient injectes sur une reponse motrice adaptee. L’evaluation de la qualite du bloc sensitif etait realisee a la 30e minute dans les territoires des nerfs tibial, fibulaire et cutane posterieur de la cuisse. Le succes du bloc parasacre etant defini par l’extension du bloc sensitif dans les territoires des nerfs tibial et fibulaire. Les complications etaient notees (ponction vasculaire et penetration intrapelvienne). Un observateur independant a enregistre : le temps de realisation des blocs, la profondeur a laquelle la stimulation etait appropriee sciatique, et le nombre de redirections d’aiguille, ainsi que la qualite de blocage nerveux du patient et la satisfaction des patients. Resultats Le taux de reussite etait de 95 % (19 des 20 cas), 75 % des blocs ont ete realises par des residents en cours de formation. Le point P etait determine des la premiere tentative. Le temps necessaire pour effectuer le bloc etait de 3 ± 1,7 min et la profondeur de la stimulation appropriee sciatique etait de 81 ± 17 mm. Le taux de satisfaction des patients etait de 85 %. Une ponction vasculaire a ete observee. Il n’y a pas eu d’autres complications. Discussion L’acces au foramen ischiatique parait facilite par ces nouveaux reperes de surface simples, pratiques et fiables. Nos reperes semblent etre plus adaptes a tous les morphotypes.

Resume Les auteurs rapportent leur experience dans le traitement des pertes de substance osseuse par transport osseux segmentaire utilisant le materiel d’Ilizarov. Neuf patients ont ete traites par cette methode entre 1996 et 2003. La serie comprend cinq hommes et quatre femmes d’âge moyen 20 ans. La perte de substance osseuse a ete secondaire a un traumatisme dans cinq cas, a une resection d’un foyer de pseudarthrose congenitale de jambe dans trois cas et a une osteomyelite dans un cas. Elle a ete de siege metaphysaire inferieur de la jambe dans sept cas, diaphysaire de la jambe dans un cas et metaphysaire inferieur du femur dans un cas. La majorite des patients ont ete operes a plusieurs reprises avant le choix de cette technique. L’etendue de la perte de substance osseuse a varie entre 2 et 8 cm, avec une moyenne de 4,1 cm. Un raccourcissement du membre allant de 1 a 6 cm a ete associe dans six cas. Les resultats ont ete analyses avec un recul moyen de 28 mois. Les difficultes et incidents techniques rencontres ont ete une corticotomie incomplete dans un cas, une erreur de sens de distraction dans un cas et une invagination cutanee dans un cas. A la fin de la distraction, la perte de substance osseuse a ete comblee pour tous les patients. Un apport osseux a ete realise a la fin du transport osseux chez six patients. La longueur d’os neoforme a ete de 4,5 cm en moyenne. L’index de distraction moyen a ete de 14 jours par centimetre. Le delai de consolidation a ete de neuf mois en moyenne. L’index de fixation externe moyen a ete de 57 jours par centimetre. Aucune infection n’est survenue. Une deviation axiale a ete observee dans quatre cas. Le resultat osseux a ete excellent dans trois cas, bon dans quatre cas et moyen dans deux cas. Le resultat fonctionnel a ete excellent dans un cas et bon dans huit cas. La technique de l’ascenseur permet le comblement des pertes de substance osseuse difficiles a traiter par les autres techniques, sa realisation comporte plusieurs difficultes et de complications qu’il faut prevenir par une realisation rigoureuse et adaptee a chaque cas.

Resume Le pied convexe congenital est une malformation rare du pied qui pose plusieurs problemes d’ordre diagnostique et therapeutique. De nombreuses techniques de correction chirurgicale ont ete proposees. Nous rapportons dix cas de pied convexe congenital non idiopathique, traites chirurgicalement selon la meme technique operatoire sur une periode de six ans avec un recul minimal de cinq ans. La malformation etait secondaire a une arthrogrypose dans cinq cas, a un syndrome polymalformatif dans quatre cas et a une diastematomyelie dans un cas. La technique chirurgicale comportait deux abords : un abord posteromedial permettant une liberation des releveurs du pied, une desinsertion du tibial posterieur, une ouverture de l’articulation talo-naviculaire et une liberation du tendon d’Achille et de la capsule tibiotalienne posterieure et un abord lateral permettant l’allongement des tendons fibulaires et une osteotomie de l’apophyse anterieure du calcaneum. Les resultats ont ete bons dans cinq cas et moyens dans cinq cas. Les resultats moyens ont ete observes dans les cas d’arthrogrypose. On a observe une hypocorrection dans deux cas et un aspect de pied plat valgus dans trois cas. Une necrose du talus est survenue dans un cas et une necrose du naviculaire dans deux cas. La technique utilisee a permis la correction simultanee des differentes anomalies du pied convexe congenital et a donne des resultats anatomiques et fonctionnels satisfaisants.

Resume Nous rapportons une etude de 15 luxations traumatiques de hanche chez 14 enfants d’âge moyen huit ans, afin de preciser leurs particularites epidemiologiques, therapeutiques et leur evolution a long terme. Nous avons note 13 luxations posterieures et deux luxations anterieures. Le delai de reduction a ete inferieur a trois heures dans huit cas, entre trois et six heures dans cinq cas et superieur a six heures dans deux cas. Apres reduction, une traction collee a ete realisee chez neuf enfants, suivie chez cinq d’une immobilisation. Dans cinq cas, une immobilisation a ete faite directement. Nous avons individualise deux groupes differents selon l’âge : groupe 1 : les luxations du petit enfant jusqu’a six ans (sept enfants) qui sont caracterisees par la benignite du traumatisme. La luxation est pure, sans lesions associees. Un terrain predisposant (hyperlaxite ligamentaire manifeste, insuffisance de couverture superoexterne de la tete femorale, coxa valga) a ete retrouve chez six enfants. La reduction etait facile. Le traitement ulterieur a consiste en une immobilisation par un plâtre pelvipedieux pendant 30 a 45 jours ; groupe 2 : les luxations du grand enfant de plus de six ans (sept enfants) qui font suite a un traumatisme violent. Les lesions associees sont frequentes. Un terrain predisposant n’a pas ete retrouve. Au recul moyen de 11 ans, toutes les hanches ont ete jugees normales a l’examen clinique. La radiographie a ete normale dans 14 hanches. Dans un seul cas, une legere coxa magna a ete retrouvee. Chez trois patients, le defaut de couverture de la tete femorale a persiste. La coxa valga a persiste chez deux patients. Les luxations traumatiques de la hanche chez l’enfant different de celles de l’adulte par leur rarete et leur meilleur pronostic. Toutefois, leurs caracteristiques epidemiologiques et therapeutiques chez l’enfant de plus de six ans rejoignent celles de l’adulte.

Resume La fracture supra-condylienne de l’humerus est de loin la plus frequente des fractures du coude chez l’enfant et la plus pourvoyeuse de complications nerveuses. Notre objectif est d’etudier le profil clinique et evolutif de ces lesions nerveuses. Nous avons etudie l’evolution de l’atteinte nerveuse chez 55 enfants. II s’agissait de 28 paralysies du nerf radial, 20 paralysies du nerf median et 7 paralysies du nerf ulnaire. Dans 32 cas, la lesion nerveuse a ete diagnostiquee avant le traitement alors que dans 23 cas, elle a ete decouverte apres le traitement. Pour les lesions nerveuses diagnostiquees avant le traitement, la recuperation a ete spontanement complete dans tous les cas et dans un delai maximal de 4 mois. Alors que pour les lesions decouvertes apres le traitement, la recuperation spontanee a ete obtenue dans 20 cas. Le delai de recuperation a ete de moins de 4 mois dans 12 cas et entre 5 et 10 mois dans 8 cas. Les 3 autres ont necessite une exploration nerveuse avec une neurolyse dans deux cas et une greffe nerveuse dans 1 cas. Dans le deuxieme groupe, la lesion nerveuse est soit causee, soit aggravee par le traitement. Ceci souligne la necessite de rechercher minutieusement une lesion nerveuse meme incomplete devant toute fracture supra-condylienne du coude chez l’enfant et la plus grande douceur lors de la reduction de ces fractures meme si l’examen initial ne met pas en evidence de lesion nerveuse.

Recently cardiac peptides have received close attention as cardiovascular markers. Brain (B type) natriuretic peptide is a neurohormone synthesized predominantly in ventricular myocardium. Previous studies have shown that this hormone can provide prognostic information in patients with myocardial infarction. The aim of this review is to evaluate the impact of plasma levels of BNP on prediction of left ventricular ejection fraction and remodelling and major cardiac events after myocardial infarction.

We report a case of osteoid osteoma of the olecranon which developed in the greater sigmoid cavity. The patient was a 22-year-old male who complained of arthritic-like symptoms limited to the elbow joint and progressing for three years. Rheumatoid arthritis then tuberculosis were entertained as possible diagnoses. The diagnosis of osteoid osteoma was not established until the disease had progressed for three years and had already become stiff due to epiphyseal remodeling. Resection of the nidus only alleviate pain and joint motion was not improved.

Resume L’aortite syphilitique est une arterite obliterante des vasa-vasorum responsable d’une reponse inflammatoire locale avec developpement de lesions anevrysmales au niveau de la paroi aortique. Cette pathologie, jadis tres frequente, est devenue exceptionnelle de nos jours grâce a la decouverte des antibiotiques. Nous rapportons l’observation d’un patient âge de 65 ans sans antecedents pathologiques notables hospitalise pour dyspnee, toux et gene thoracique. Les differentes explorations radiologiques, echocardiographiques, scanographiques et par resonance magnetique ont montre un anevrysme de l’aorte ascendante etendu jusqu’a la naissance du tronc arteriel brachio-cephalique. L’origine syphilitique a ete retenue devant la positivite des examens serologiques avec un profil de syphilis tertiaire et l’absence d’arguments en faveur d’une autre etiologie. Le patient a beneficie d’un remplacement de l’aorte ascendante par prothese en dacron avec reimplantation du tronc arteriel brachiocephalique, sans incidents. Notre observation a le merite d’attirer l’attention sur cette pathologie devenue exceptionnelle a travers une riche iconographie incluant les outils diagnostiques les plus recents. (J Mal Vasc 2006; 31: 93-97)

Resume Objectifs Etudier la validite et la reproductibilite des mesures de la mobilite globale et segmentaire en flexion du rachis lombaire evaluees par le Spinal Mouse®. Materiels et methodes Pour l'etude de la validite des patients lombalgiques ont participe a l'etude ; chaque patient a eu deux radiographies : une radiographie du rachis lombaire de profil en position debout, et l'autre en flexion maximale du tronc. La correlation entre les mesures radiographiques et celles du Spinal Mouse® a ete evaluee par le coefficient de correlation de Spearman (CCS). La reproductibilite a ete evaluee chez des sujets sains en utilisant le coefficient de correlation intraclasse (CCI). Resultats Vingt patients lombalgiques (huit femmes) d'âge moyen 41,6 ± 8,6 ans (limites : 24–63) ont ete inclus pour l'etude de la validite. Le CCS entre les mesures radiographiques et celles du Spinal Mouse® etaient 0,55 ; 0,64 ; 069, 0,54 ; 0,19 ; 0,7 et 0,86 pour les etages L1–L2, L2–L3, L3–L4, L4–L5, L5–S1, L1–L5, et L1–S1. Quarante-cinq patients sains d'âge moyen 24,2 ± 3,7 ans (limites : 20–29) ont ete inclus pour l'etude de la reproductibilite. Pour la reproductibilite intraobservateur le CCI etait de 0,84 ; 0,89 ; 0,96 ; 0,97 ; 0,6 ; 0,95 et 0,83 respectivement pour les etages L1–L2, L2–L3, L3–L4, L4–L5, L5–S1, L1–L5 et L1–S1. Pour ces memes mesures la reproductibilite interobservateur trouve un CCI respectivement evalue a 0,75 ; 0,71 ; 0,81 ; 0,79 ; 0,6 ; 0,83 et 0,85. Conclusion Le Spinal Mouse® est un outil de mesure rapide, facile et objectif. Ses qualites metrologiques sont acceptables pour evaluer la mobilite globale et segmentaire en flexion du rachis lombaire. Ses qualites metrologiques restent insuffisantes pour l'etude de la mobilite en flexion de la charniere lombosacree (L5–S1).

Resume Les auteurs rapportent un cas de luxation septique de la hanche chez un nourrisson de 8 mois, secondaire a une vaccination par le BCG. Le traitement habituel d’une arthrite septique comportant un drainage chirurgical et une antibiotherapie a large spectre n’a pas ete suffisant. C’est a la suite de sa mise sous traitement anti-tuberculeux et d’un deuxieme drainage chirurgical que la guerison a ete obtenue. Cette complication rare du BCG, peut survenir plusieurs mois apres l’administration du vaccin; elle est de diagnostic souvent difficile au vu du caractere fruste et non specifique des signes cliniques et radiologiques au debut et les difficultes de mise en evidence du germe responsable. Le diagnostic de certitude est souvent apporte par la biopsie et l’examen anatomo-pathologique. Malgre la virulence attenuee du germe, un traitement anti-tuberculeux est indispensable pour assurer la guerison; le drainage chirurgical seul est insuffisant.

Arthrogryposis is a condition existing at birth, seen in different diseases that have in common the existence of multiple joint stiffness. The clinical presentation is diversified and the functional prognosis depends on the etiology, which makes therapeutic options different from one case to another. The objective of this study was to describe clinical manifestations observed in arthrogrypotic patients and show the different therapeutic methods and functional results.This was a retrospective study over a period of 12 years from 2000 to 2012, based on clinical examinations of 23 patients with arthrogryposis.The mean age of the patients was 6.6 years. The four limbs were involved in 19 cases and only the lower limbs in four cases. The etiology was amyoplasia in nine patients, distal arthrogryposis in three, peripheral neuropathy in two, and muscular atrophy in one infantile patient. Foot deformities were observed in 22 cases, with 25 talipes equinovarus deformities (clubfoot), six convex feet, and five valgus feet. The Ponseti method was applied in 12 clubfeet with recurrence in eight cases. The other clubfeet had functional treatment and necessitated surgical release in 11 cases. Deformation of the knee was seen in 15 patients, flessum in 16 knees, restriction of flexion in eight cases, genu recurvatum in three, stiffness in extension in two, and agenesis of the patella in one case. Surgical treatment was carried out in only one case. Other cases of deformity of the knee were treated by rehabilitation with slight improvement. Deformation of the hip was seen in 15 patients, with 16 hips dislocated and four hips in flessum. The dislocation of the hip was treated orthopaedically in two cases and surgically in six cases, with reduction in all cases but persistence of stiffness. Involvement of the shoulders was observed in eight cases, the elbow in seven cases, the wrist in ten cases, and the fingers in 16 cases. The treatment was based on physical therapy and orthotics in all cases, and improvement was better in the wrist and fingers.Arthrogryposis has different clinical presentations. Successful treatment is not constant. Multidisciplinary care is necessary and should be early and continued in order to gain the maximum autonomy and facilitate patients' social integration.

Chronic granulomatous disease is a rare, primary immunodeficiency disorder characterized by a defect in oxidative metabolism in phagocytes and recurrent bacterial and fungal infections. We report a case in a 2-month-old infant admitted with metacarpic osteomyelitis due to Serratia marcescens. Chronic granulomatous disease is rare but must be considered in cases of uncommon or atypical infection.

Introduction Obstructive sleep apnea (OSA) is associated with several cardio-vascular abnormalities as atrial fibrillation (AF). AF occurrence in OSA increases the risk of stroke which worsens the prognosis of these patients. P wave dispersion (Pd) and maximal P wave duration (P max) are simple electrocardiographic parameters which reflect atrial conduction abnormalities and have been reported to be predictors of atrial fibrillation Aim the aim of this study is to determine the correlation between apnea-hypopnea index (AHI) and P wave dispersion and maximal P wave duration. Methods Forty patients (18 men and 22 women) who were diagnosed with OSA by overnight polysomnography were included in this prospective study. The mean age was 56±10 years old. They were all in sinus rhythm. Before initiating continuous positive airway pressure therapy, we evaluated on a 12 lead ECG P wave duration and P wave dispersion (P max - P min). Results Twenty four patients had severe OSA (AHI >30), 4 had moderate OSA (AHI between 15 and 30) and 12 had a mild OSA (AHI between 5 and 15). Mean P max duration was 119±21 ms. P wave dispersion was 93±6 ms. There was a significant positive correlation between P max and AHI (r= 0.45, p=0.001) and between P wave dispersion and AHI (r=0.42, p=0.001) Conclusion The severity of OSA seems to be correlated with the importance of atrial conduction abnormalities. These results suggest the higher is the AHI the higher is the risk of AF occurrence in OSA. Further studies are needed to validate these results.

Cleidocranial dysplasia or dysostosis involves dental anomalies, bone abnormalities with membranous ossification (clavicles, cranium, face, pelvis), rarely of the spine and the remainder of the skeleton. We report 2 new cases and describe the different clinical aspects of this disorder and the orthopedic problems that it can pose. The clinical demonstrations of this disease are highly variable and inconsistent, which explains the diversity of circumstances of discovery. Abnormalities of the face and clavicles, as well as of pelvic ossification are most frequent and can be regarded as major signs. These clinical demonstrations do not require treatment in the majority of the cases. Dental anomalies, coxa vara and scoliosis require regular monitoring and treatment in the event of progressive aggravation. The incomplete penetrance of this autosomal dominant disease and its good tolerance explain the frequency of undiagnosed forms, whose clinical expression is discrete.

Melanomas of digit is rare, accounting for 1% of all cutaneous melanomas. We report a new case.Our purpose is to discuss the clinicopathological characteristics and the difficulties encountred in establishing diagnosis of this rare tumor.we report the case of a 25-years-old woman, who consulted for nodular and ulcerated lesion of the right index, located in the external face of the metacarpo-phalangeal joint. The nodule was biopsied and histopathologic exam concluded to spitzoid melanoma. The surgical margins were involved. The patient refused surgical recovery. She consulted 3 years later with axillary lymph nodes. A wide excision of the tumor with lymph node biopsy were made. Histological study concluded to a tumoral residu incompletely excided with lymph node metastases. Amputation of the second digit with dissection of the axillary lymph nodes was made. The surgical margins were tumor free. Lung metastases appeared with a follow up of two months. The patient died early after starting chemotherapy with Deticen.In our report, clinical presentation was misleading causing a diagnosis and therapeutic delay. Pathologically, all the histological types of melanoma were described in the digit except spitzoid melanoma.

Bone hydatid disease is a rare pathology, characterized by its long clinical latency, the absence of radiological specificity as well as its challenging surgical treatment. We report an observation of pelvic bone hydatidosis in a 28-year-old patient, appearing with pain and stiffness of the hip as well as a degenerative aspect on the coxofemoral joint on X-ray. The treatment consisted of an extensive hemipelvectomy with femoro pelvic arthrodesis, completed by medical treatment. The functional result was excellent in spite of a break in the fixation material, which allowed a certain mobility at the proximal end of the femur. Hydatid disease of bone is infiltrating,diffuse, slow, and progressive, all characteristics explaining the often-delayed diagnosis. Medical imaging provides accurate analysis for planning a broad surgical resection. The quality of surgical resection is determined according to the risk of recurrence. Pelvic locations are particularly difficult to treat. After an enlarged and difficult surgical resection, reconstruction remains aleatory and poses many technical problems.

The usual technique of parasacral sciatic nerve block seems an approach easily achieved, however, the ischial tuberosity is difficult to palpate. [1] The purpose of the study was to propose new skin landmarks improved by an anatomical and clinical study.Three cadaver dissections made previously have shown that our skin landmarks appeared correct. Twenty consenting patients, ASA I to III, proposed for lower limb surgery, were included in this descriptive and prospective study. The patient was positioned in the Sim position. A line was drawn between the anterior superior iliac spine (ASIS) and the sacral hiatus (HS). A second line was drawn from the posterior superior iliac spine (PSIS) and perpendicular to the 1st line. The puncture site (P) was the intersection of these two lines. At point P, the needle was inserted perpendicularly to the skin. Twenty milliliters of a mixture of lidocaine 2% and bupivacaine 0.5% were injected after obtaining an appropriate motor response. Sensory block was assessed 30 minutes after performing block in the territories of the tibial nerve, peroneal and posterior cutaneous of thigh. Parasacral block success was defined by the extension of sensory block in the territories of the tibial and fibular nerves. Complications were noted. An independent observer recorded: the time to perform blocks, the depth of the sciatic nerve, the number of needle redirections, the quality of nerve block of patient, and patient satisfaction.The success rate was 95% (19 of 20 cases). Seventy-five percent of blocks were performed by residents on training. The point P was determined at the first attempt. The time required to perform the block was 3 + or - 1.7 min and depth of the sciatic nerve was 81 + or - 17 mm. The rate of patient satisfaction was 85%. One vascular puncture was observed. We have not noted other complications.Access to the sciatic foramen appears to be facilitated by these new surface landmarks, which are simple and reliable. Our new skin landmarks seemed valid for all morphotypes.

Ilizarov's segmental bone transport technique is one of the treatments of bone defects. The aim of our investigation was to identify which technical specific features could ensure the success of this surgical option and to analyze the various difficulties and complications inherent in this method.Our analysis covered a series of nine patients - five males and four females with a mean age of 20 years old - all treated by bone transport between 1996 and 2003. Bone loss was secondary to a traumatism in five cases, to the excision of a tibial congenital pseudoarthrosis in three cases and to an osteomyelitis in one case. Bone defect was reported to be located in the tibial distal metaphysis in seven cases, in the tibial diaphysis in one case and in the distal femoral methaphysis in another case. In most cases, bone transport was performed as revision surgery after previous unsuccessful surgical attempts. The mean length of the bone defect was 4.1cm (range: 2 to 8 cm). A shortening of the limb - ranging 1 to 6 cm - was associated with bone loss in six cases. The average follow-up period was 28 months (range 10 to 96 months).The reported difficulties and technical incidents encountered with this method included one incomplete corticotomy, one distraction which was performed in the wrong direction, and one case of cutaneous invagination and axial deviation of the lower limb. At the end of the distraction phase, union was achieved in all cases. At the end of transport, six patients required supplemental bone grafting of the docking site to improve healing. The average size of bone formation was 4.5 cm (range: 3 to 8 cm). The mean distraction index was 14 days per centimeter. The mean time between external fixation and healing was nine months for eight patients. The mean external fixation index was 57 days per centimeter. No infection at the non-union and distraction site was reported. An axial deviation was observed in four cases. Bony reconstruction was excellent in three cases, good in four cases and fair in two cases. All patients could return to normal activity at the end of the treatment. Functional outcomes were excellent in one case and good in eight cases.Ilizarov's segmental bone transport technique is a reliable option for the treatment of bone defects that other surgical procedures failed to manage. However, the different technical difficulties and complications inherent in this method require the need for a meticulous planning, adapted to each surgical case.

Congenital pes valgus is a rare and complex deformity of the foot raising serious diagnostic and therapeutic challenges. The purpose of our work was to present the surgical procedures used in our series and to analyze outcome.Ten feet presenting congenital convex valgus treated surgically over a six-year period using the same operative technique were reviewed at minimum five years follow-up. Idiopathic deformities were excluded from this series. Deformities were secondary to arthrogryposis in five feet, a multiple malformative syndrome in four and diastematomyelia in one. The surgical technique used two approaches: a posteromedial incision to release the dorsal flexors, disinsert the tibialis posterior, open the talonavicular joint, release the Achilles tendon and release the posterior tibiotalar capsule; a lateral incision to lengthen the fibular tendons and perform an osteotomy of the anterior process of the calcaneum. A talonavicular pin and a calcaneocuboid pin maintained the correction. The tibialis posterior tendon was reinserted on the anterior aspect of the talonavicular capsule after incision of the dislocation chamber.Outcome was considered good in five cases and fair in five. Outcome was fair in the arthrogyrposis feet. Undercorrection was observed in two feet and valgus flatfoot in three. Talar necrosis occurred in one foot and navicular necrosis in two.Simultaneous correction of the different anomalies observed in the congenital convex foot was achieved in this series. The anatomic and functional results were satisfactory. We recommend avoiding overly extensive release in order to decrease the risk of talar and navicular necrosis. It is also important to check the reduction radiographically during the operation. Patients should use an orthesis several months postoperatively to avoid recurrence.

Summary Purpose of the study Congenital pes valgus is a rare and complex deformity of the foot raising serious diagnostic and therapeutic challenges. The purpose of our work was to present the surgical procedures used in our series and to analyze outcome. Material and methods Ten feet presenting congenital convex pes valgus treated surgically over a six-year period using the same operative technique were reviewed at minimum five years follow-up. Idiopathic deformities were excluded from this series. Deformities were secondary to arthrogryposis in five feet, multiple malformative syndrome in four, and diastematomyelia in one. The surgical technique used two approaches: a posteromedial incision to release the dorsal flexors, disinsert the tibialis posterior, open the talonavicular joint, release the Achilles tendon and release the posterior tibiotalar capsule; a lateral incision to lengthen the fibular tendons and perform an osteotomy of the anterior process of the calcaneum. A talonavicular pin and a calcaneocuboid pin maintained the correction. The tibialis posterior tendon was reinserted on the anterior aspect of the talonavicular capsule after incision of the dislocation chamber. Results Outcome was considered good in five cases and fair in five. Outcome was fair in the arthrogryposis feet. Undercorrection was observed in two feet and valgus flatfoot in three. Talar necrosis occurred in one foot and navicular necrosis in two. Discussion Simultaneous correction of the different anomalies observed in the congenital convex foot was achieved in this series. The anatomic and functional results were satisfactory. We recommend avoiding overly extensive release in order to decrease the risk of talar and navicular necrosis. It is also important to check the reduction radiographically during the operation. Patients should use an orthesis for several months postoperatively to avoid recurrence.

Traumatic hip dislocation is a rare event in children. Appropriate management remains a subject of debate. The purpose of this study was to investigate the epidemiological, therapeutic features of this situation and the long-term outcome after treatment.This was a retrospective analysis of 15 traumatic hip dislocations collected over a period of 20 years in pediatric patients with at least two years follow-up. We searched for predisposing factors and factors affecting prognosis.The series included 11 boys and three girls, mean age eight years. Dislocation was posterior in 13 hips and anterior in two. Time to reduction was less than 3h in eight cases, 3-6h in five and greater than 6h in two. After reduction, traction was performed in nine children, for 20 days on average, followed in five cases by immobilization for 40 days on average. Five hips were immobilized directly after reduction. We identified two groups by age: group 1 with dislocations in children aged less than six years (seven children) were characterized by low-energy trauma. Dislocation was not associated with other lesions. Predisposing factors (overt ligament hyperlaxity, insufficient superolateral head cover, coax valga) were noted in six children. Reduction was simple. Later treatment consisted in immobilization with a pelvispedious cast for 30-45 days. Group 2 were dislocations in children aged over six years (seven children) victims of high-energy trauma. Associated injuries were frequent. Predisposing factors were not present. At mean 11 years follow-up, all hips are considered normal clinically. The radiograph was normal for 14 hips. In one case, there was a slight coax magna. In three patients, defective femoral head cover persisted. Coxa valga persisted in two patients.Traumatic dislocation of the hip joint is rare in very young children, but results from a minimally traumatic event. This suggests the presence of predisposing factors in this category of patients, particularly capsuloligamentary hyperlaxity. After reduction, immobilization can be recommended. Traumatic hip dislocations in children are different from the adult variety due to their rarity, the general absence of associated fractures, easy reduction and better prognosis. The epidemiological and therapeutic features in children older than six years are however similar to those in adults.

The most frequent type of elbow fracture in children is by far the supracondylar fracture. This type of fracture also raises the greatest risk of nerve injury. We wanted to study the clinical and prognostic features of nerve injuries in children presen-ting supracondylar fractures of the humerus.We analyzed the files of 55 children with nerve lesions identified among 1 180 files on supracondylar fractures in children. Most presented Lagrange and Ribault stage IV fractures. Nerve injuries involved the radial nerve (n=28), medial nerve (n=20), and ulnar nerve (n=7). The nerve injury was diagnosed before treatment in 32 children, and after treatment in 23. When nerve injury was identified before treatment, closed reduction had been used for eleven fractures and open reduction for 21. Nerve injury identified after treatment was found in eleven fractures after closed reduction and in 12 fractures after open reduction.When nerve injury was recognized at the initial examination, spontaneous nerve recovery was achieved in all cases, irrespective of the treatment modality, within a maximum of four months. When nerve injury was recognized after treatment, spontaneous nerve recovery was obtained in twenty cases. Time to recovery was longer. The three other cases required nerve exploration with neurolysis for two and a nerve graft for one.Nerve injury discovered after treatment is either caused by or aggravated by the treatment. Prognosis is less favorable than for injuries discovered at the initial examination. This highlights the importance of carefully searching for nerve deficit, even partial deficiency, in all children presenting a supracondylar fracture of the humerus. It also emphasizes the importance of care in obtaining bone reduction if the initial examination did not reveal any nerve deficit.

We report a case of osteoid osteoma of the olecranon which developed in the greater sigmoid cavity. The patient was a 22-year-old male who complained of arthritic-like symptoms limited to the elbow joint and progressing for three years. Rheumatoid arthritis then tuberculosis were entertained as possible diagnoses. The diagnosis of osteoid osteoma was not established until the disease had progressed for three years and had already become stiff due to epiphyseal remodeling. Resection of the nidus only alleviate pain and joint motion was not improved.

Recently cardiac peptides have received close attention as cardiovascular markers. Brain (B type) natriuretic peptide is a neurohormone synthesized predominantly in ventricular myocardium. Previous studies have shown that this hormone can provide prognostic information in patients with myocardial infarction. The aim of this review is to evaluate the impact of plasma levels of BNP on prediction of left ventricular ejection fraction and remodelling and major cardiac events after myocardial infarction.

The incidence of tertiary syphilis has declined in recent years owing to the early recognition of the disease and use of antibiotics. As a result, syphilitic aortic aneurysms are rarely encountered nowadays. We report the case of a 65 years old man, who was admitted to our hospital in June 2004 for dyspnea, cough and chest discomfort. On physical examination, blood pressure was 130/80 mmHg with no significant laterality, pulse rate was 70 per minute and there was a decrease of breath sounds over the right lung. Laboratory findings revealed a slight elevation of the erythrocyte sedimentation rate. Serological studies for syphilis showed a positive venereal disease laboratory test (VDRL) at 1/32 and a positive Treponema pallidum hemagglutination test (TPHA) at 1/2560. The chest radiography showed a right para cardiac opacity measuring 16 x 12 cm. Fiber optic bronchoscopy showed an extrinsic compression of the right upper lobar bronchus. Gadolinium-enhanced magnetic resonance angiography and 16 multidetector-row spiral computed aortography showed a huge partially thrombosed saccular aneurysm of the ascending aorta measuring 132 mm in diameter. The circulating lumen measured 53 mm in its largest diameter. This aneurysm involved the innominate artery. There was no other arterial involvement. The patient was given a three week course of intravenous penicillin followed by a successful surgical procedure in September 2004 with ascending aortic replacement and innominate artery reimplantation. This case illustrates well a formerly common, but now extremely rare disease.

We report a case of septic dislocation of the hip in an eight-month-old infant secondary to BCG vaccination. The usual treatment of septic arthritis with surgical drainage and broad spectrum antibiotics was unsuccessful. Cure was achieved after institution of an anti-tuberculosis treatment and a second surgical drainage. This rare complication of BCG vaccination can develop several months after administration of the vaccine. Diagnosis is often difficult to establish due to the minimal clinical and non-specific clinical expression. Early radiological signs are also non-specific. Identification of the causal agent can be most difficult. Certain diagnosis is generally achieved after biopsy and pathology examination. Despite the attenuated virulence of the vaccine, anti-tuberculosis treatment is indispensable to achieve cure. Surgery drainage alone is insufficient.

Introduction Several studies proved that obstructive sleep apnea (OSA) is associated with cardio-vascular diseases such as cardiac arrhythmia. QT duration and dispersion reflect the heterogeinity of ventricular repolarization and are considered as precursors of ventricular arrhythmia Aim The aim of this study is to assess the relation between the severity of OSA parameters as apnea hypopnea index and QT intervals. Methods Forty patients (18 men and 22 women) who were diagnosed with OSA by overnight polysomnography were included in this prospective study. The mean age was 56±10 years old. They were all in sinus rhythm. Before initiating continuous positive airway pressure therapy, we calculated on a 12 lead ECG : QT duration (QTend) corrected to Bazett formula and QT dispersion (QT end max -QT end min). Results Twenty four patients had severe OSA (AHI >30), 4 had moderate OSA (AHI between 15 and 30) and 12 had a mild OSA (AHI between 5 and 15). There was a significant positive correlation between QT dispersion and AHI (r=0.48, p=0.001) Conclusion The severity of OSA seems to be correlated with ventricular repolarization heterogeinity These results suggest that the higher is the AHI the higher is the risk of ventricular arrhythmia occurence. Further studies are needed to validate these results.

The purpose of this study was to report the clinical course and outcome in 12 patients with extra-abdominal desmoid tumors.This retrospective series included 12 patients with extra-abdominal desmoid tumors treated between 1987 and 1996. Female gender predominated (8/12) and age ranged from 4 months to 60 years. The tumors were identified in the thoracic wall (n=2), the upper limb (n=4), and the lower limb (n=6) with a bony localization in the upper femoral metaphysis. Magnetic resonance imaging was highly contributive to the search for extension. Surgical treatment was given in all cases. All patients were living at last follow-up.Complete resection was achieved in three patients and incomplete resection in nine. Mean follow-up was seven years. There was one case of sarcomatous transformation and nine cases of recurrence. Mean time to recurrence was one year (range 6 months-4 years). Two tumors, in the forearm and the leg, did not recur. Secondary surgery was not attempted in four patients whose clinical situation has remained stable after recurrence. A second resection was performed for recurrence in four other patients who then remained recurrence-free to last follow-up. One tumor recurred three times after surgical resection. Functional outcome was good in nine patients.The poorly limited nature of extra-abdominal desmoid tumors makes resection a difficult task, particularly when located in the girdles or the most proximal part of the limbs. Wide first-intention surgical resection is recommended but mutilation must be avoided due to the benign nature of the tumor, its slow progression, and the possibility of regression or stability after recurrence. Nevertheless, surgical treatment of recurrent tumors is difficult and often insufficient, compromising functional outcome. Complementary treatment (radiotherapy) has been advocated for better control tumor growth.

Giant-cell tumors are an infrequent clinical, radiological, and pathological entity observed in 5% of primary bone tumors. They generally occur at the epiphysis of long bones, particularly in the knee area but patellar localization seems very rare. Despite their perfectly benign histological aspect, giant-cell tumors may be aggressive, leading to local recurrence or even distant metastasis to the lung. We report a case of benign giant-cell tumor of the patella with lung metastasis observed in a 23-year-old woman. The aggressive radiological image was suggestive of chondrosarcoma. Histologically the differential diagnosis with chondroblastoma was difficult. The tumor and lung metastasis were treated by surgical resection. Four years later there has been no recurrence. We present the anatomic and clinical aspects of giant-cell tumor of the bone together with the diagnostic approach and the clinical course.

Hydatid pulmonary embolism is an uncommon condition resulting from the rupture of a hydatid heart cyst or the opening of a visceral hydatid cyst (often in the liver) into the venous circulation. We report two cases of hydatid pulmonary embolism following rupture of a hydatic cyst in the right ventricle. One case progressed to chronic cor pulmonale. We examine the pathophysiological mechanisms as well as the clinical, therapeutic and evolutive aspects.

Objectif Analyser les facteurs qui peuvent influencer le resultat final de l’osteotomie de Salter dans la dysplasie residuelle de la hanche et preciser ses indications. Materiel et Methode nous avons mene une etude retrospective de 31 osteotomies de Salter pour la correction d’une dysplasie residuelle de hanche. Tous les enfants ont eu un traitement orthopedique selon la methode de Sommerville-Petit. La technique operatoire a ete la meme pour tous les enfants. Une tenotomie des adducteurs et du psoas a ete realisee de facon systematique. Lors de la bascule acetabulaire, nous avons essaye d’exagerer la bascule laterale, avec un minimum de translation anterieure de l’acetabulum. Le recul a ete superieur a deux ans dans tous les cas. Pour evaluer la bascule acetabulaire, nous avons utilise des criteres radiologiques d’une bonne bascule. L’evaluation des resultats a ete clinique selon les criteres de Mc Kay, radiologique selon Severin et globale selon les criteres de Mac Farland. Resultats Huit enfants ont ete operes des deux cotes en un seul temps operatoire. L’âge moyen lors de l’osteotomie de Salter etait de 4 ans 2 mois avec des extremes de 2 ans et 6 ans. Le delai moyen entre traitement orthopedique et chirurgie etait de 2 ans 2 mois. Les resultats fonctionnels globaux etaient excellents dans 62 % des cas. Les excellents resultants diminuent avec l’âge de chirurgie. Le resultat radiologique etait bon dans 94 %. Les meilleurs resultats radiologiques ont ete constates pour un âge de chirurgie moyen de 4 ans 3 mois, pour les hanches les moins couvertes et les dysplasies les moins severes. L’analyse du resultat global a montre que 29 hanches (94 %) ont ete affectees au grade 1 ou 2. Conclusion L’osteotomie de Salter est une intervention simple qui permet de rattraper le retard de croissance acetabulaire. Les facteurs qui influencent le resultat final sont l’âge au moment de la chirurgie et l’importance de la bascule sur la radio post-operatoire. En cas de dysplasie bilaterale, une chirurgie en un seul temps est recommandee pour les avantages qu’elle offre en particulier un meilleur resultat radiologique. L’âge ideal de sa realisation se situe autour de 4 ans. Son succes est etroitement lie au choix approprie de l’indication et d’une technique chirurgicale meticuleuse.

The authors report 2 cases of isolated traumatic anterior dislocation of the radial head in children. In the first case, with an acute dislocation, closed reduction followed by plaster cast immobilisation for one month gave a good result. In the second case, the dislocation was also traumatic in origin but had remained unreduced for 5 years. Arthrography of the elbow showed the head to be intracapsular. The authors believe that a neocapsule forms in cases of old unreduced dislocation and arthrography is therefore of little help to differentiate a long standing traumatic dislocation from a congenital dislocation. Based on their experience and on the literature, the authors propose closed reduction followed by immobilisation as a treatment for acute dislocation; old unreduced dislocations cannot be reduced by manipulation and with the exception of very symptomatic cases, the authors prefer to avoid open reduction, which carries a risk of joint stiffness.