Complications of the Luque-Galveston scoliosis correction technique in paediatric cerebral palsy.

PURPOSE OF THE STUDY: Severe scoliosis is a very frequent condition in cerebral palsy children (CP). It is surgically managed, with unit rod instrumentation being the gold standard in English-speaking countries. The purpose of this work was to report on a small, homogeneous series of non-ambulatory, quadriplegic, spastic patients treated by the Luque-Galveston technique in Strasbourg, France. We present the radiographic outcome of the technique along with a full description of any post-operative complications encountered. MATERIALS AND METHODS: Twenty-eight children were operated on according to the Luque-Galveston technique between January 1997 and January 2006. This instrumentation, with fusion, included the whole spine from the sacrum to level T2. All procedures were performed as a one-stage posterior arthrodesis. The spinal deformities were single thoraco-lumbar curvatures, except in one patient. Both curve magnitude and pelvic obliquity were measured by X-ray pre-operatively, post-operatively and after longest follow-up (over 24 months). Our study focused on the rate of complications of this treatment. Only 16 patients out of 28 were tracked since the remaining 12 were lost to follow-up. RESULTS: Mean curve magnitude was corrected from 80 degrees to 34.8 degrees (mean correction, 56.5%), and pelvic obliquity, from 20.9 degrees to 4.2 degrees (mean correction, 79.6%). Loss of correction at average 3.46-year follow-up was 3.9 degrees of curve magnitude and 2.7 degrees of pelvic obliquity. Mean operating time was 301.5 minutes, and average blood loss was 861.9 ml. Patients were discharged from hospital after an average 19.5-day stay, including mean 8.4-day intensive care unit stay. A single major complication, monocular blindness, occurred during the procedure, probably resulting from air embolism. Post-operative complications (totaling 57.1% of our 28 patients) were: one death, three pneumothoraxes, six segmental atelectasias, seven pneumonias and one superficial wound infection. Late-onset complications (totaling 56.2% of our 16 patients at latest follow-up) were: seven broken sublaminar wires, one iliac perforation by the rod, one skin irritation from extreme malnutrition needing hardware removal, and three superficial sacral decubitus ulcers. DISCUSSION: Our correction rate in children affected by CP and manifesting severe scoliosis is similar to that reported in the literature by different surgical teams. Moreover, we did not observe any deep wound infection, haematoma, septicaemia, neurological and digestive complications. Late-onset complications mainly involved asymptomatic sublaminar wire breakage at the two uppermost levels, but no major complication was due to hardware failure, and vertebral fracture did not occur. There was no need for re-intervention because of the hardware, except for one case in which extreme malnutrition provoked skin conflict with the rod. We encountered 10 "windshield wiper" effects in the iliac bone, but we believe they cannot be considered as complications since they seemed to disappear after fusion was fully obtained. Last but not least, unit rod instrumentation is not very expensive compared to more modern techniques. CONCLUSION: Correction of scoliosis and pelvic obliquity, attributed to CP in non-ambulatory children, by the Luque-Galveston technique is both an effective and safe choice in such an indication. Moreover, it is far less expensive than most other techniques, an aspect which should be taken into consideration. LEVEL OF EVIDENCE: Level IV retrospective therapeutic study.

Salmonella enterica subsp. arizonae bone and joints sepsis. A case report and literature review.

Osteoarticular infections caused by Salmonella enterica subsp. arizonae are rarely seen in humans but young children and immunocompromised adults are at particular risk of acquiring this bacteria. Reptiles and their by-products (e.g. meat preparations or medications) are particularly likely to harbor Salmonella. We report on a case of septic arthritis of the hip transmitted by a reptile in a 10-month-old child. We carry out a recall of the complex nomenclature of Salmonella, a review of the literature and provide information on the recommended precautions for reducing the risk of transmission of Salmonella from reptiles to humans.

Use of end caps in elastic stable intramedullary nailing of femoral and tibial unstable fractures in children: preliminary results in 11 fractures.

BACKGROUND: Elastic stable intramedullary nailing (ESIN) is used routinely world-wide for treating femoral and tibial shaft fractures in children before skeletal maturity. Overall, ESIN allows rapid limb mobilisation with few complications. However, many centres have experienced some complications resulting from secondary fracture displacement, especially in heavy adolescents and in spiroid or complex fractures due to changes in the nail's position, leading to limb shortening, malrotation and malalignment. End caps were designed by the AO expert group to address these complications. PURPOSE: The purpose of this study is to evaluate the efficiency, safety and tolerance of this new device in our first series of ten patients and 11 fractures. METHODS: Prospective follow-up of our first ten patients operated on with end caps. RESULTS: Our results show that there were no serious complications at a mean follow-up of 13.1 months. There was only one 10-mm leg shortening in a patient in whom the end caps could not be properly inserted. There were no infections, no additional pain and no skin irritation. The use of end caps eased the removal of the nails after bone healing, thereby preventing the formation of ossification over the tips of the nails and appeared to protect the skin next to the nail tip. CONCLUSION: These results seem to prove the advantage of using end caps when performing ESIN in lower limb shaft fractures in children. A longer follow-up that includes more patients and a randomised prospective study should be carried out in the future to determine more precisely the indications of this new device.

[Osteochondritis dissecans of the femoral condyles: report of 892 cases]. / L'ostéochondrite disséquante des condyles fémoraux.

PURPOSE OF THE STUDY: Osteochondritis rarely involves the femoral condyles. Discovery in this localization raises several questions concerning the nature of the articular cartilage, the potential for spontaneous healing, and, in the event of a free fragment, the outcome after its loss or repair. MATERIAL AND METHODS: This multicentric study included 892 pediatric and adult cases, the cutoff between two series being defined by fusion of the inferior growth plate. We excluded medical or surgical osteochondritis, cases involving the patella, osteochondral fractures, juvenile polyosteochondrosis, adult osteonecrosis, and osteochondritis beginning after the age of 50 years. RESULTS: Mean age at diagnosis was 16.5 years. Mean age at treatment onset was 22 years. Pain was the predominant symptom. 80% of cases were unilateral and 70% involved the medial condyle. The anatomic lesions were different in adults, showing more advanced degradation. At diagnosis, Bedouelle stages Ia and IIb constituted 80% of the cases observed among children while in adults, 66% were Bedouelle stages IIb to IV. Outcome was very good for the majority of children with Hughston clinical stage 4 while half of the x-rays were Hughston stage 3 and 4. There were thus a large percentage of children with abnormal xrays whose disease history was not yet terminated. In the adult series, the percentages of Hughston 3 and 4 was about the same as clinically. The x-rays were rarely perfectly normal since half of the clinical stage 3 patients were noted in stage 4. An abnormal x-ray with a very good clinical presentation was observed in a very large proportion of patients. DISCUSSION: It is difficult to interpret the plain x-ray and identify patients with a potentially unfavorable prognosis. We defined three radiographic classes: defect, nodule and empty notch. The Bedouelle classification uses information from all available explorations, particularly MRI and arthroscopy. Numerous therapeutic methods are used. Interruption of sports activities is the first intention treatment for children. Data in the literature and the findings of this symposium do not demonstrate any beneficial effect of immobilization on healing compared with simple abstention from sports activities. Transchondral perforation is a simple operation with low morbidity. In 85% of cases, it was used for lesions with an intact joint cartilage considered stable in 96% of cases. Healing was achieved in six months for 48% if the growth plate had not fused. The fragment was fixed in 43% of the cases with a loose cartilage fragment. Outcome was fair but degraded with the state of the joint cartilage and thus the stability of the fragment. Fixation must stabilize the fragment but not prevent further consolidation via osteogenesis. This is why deep perforations are drilled beyond the ossified area and additional osteochondral grafts are used. The Wagner operation gives less satisfactory results than more complicated procedures. Removal of a sequestrum is a simple, minimally invasive procedure with an uneventful postoperative period, but in the long term it favors osteoarthritic degradation, especially when performed in adults. Mosaic grafts give good mid term results. Morbidity is low especially if the grafts are harvested above the notch. The question of chondrolysis around the grafts was beyond the scope of this study. Chondrocyte grafting is difficult to accomplish and is expensive. The mid term results are good for large lesions. Osteotomy is logical only in the event of early stage osteoarthritic degradation. DECISION ALGORITHM IN CHILDREN AND ADOLESCENTS: If the plain x-ray reveals a defect (class I), simple interruption of sports activities should be proposed. Two situations can then develop. First, in a certain number of patients, the pain disappears as the defective zone ossifies progressively. Complete cure is frequent before the age of 12 years. In the second situation, the knee remains painful and the x-ray does not change or worsens to a class II nodular formation. In this case an MRI must be obtained to determine whether the joint cartilage is normal. There are two possibilities. First, the osteochondral fragment is viable and most probably will become completely re-integrated, particularly if the lesion is far from the growth plate. Necrosis is the other possibility. Transchondral perforations are needed in this case. If on the contrary the cartilage is altered, there is little hope for spontaneous cure. Arthroscopy may be needed to complete the exploration. Fragments, especially if there is a large surface area, must be fixed. Perforations to favor revascularization are certainly useful here. In the last situation (class III), the fragment wobbles on a thin attachment or has already fallen into the joint space. This is the type of problem generally observed in adults. The decision algorithm in adults is the same as in children for the rare nodular aspects (class II). There could be a discussion between transcartilage perforation and fixation. If there are a large number of fragments, fixation may not be fully successful and the lesion might be considered class III. For class III lesions, three operations can be used: removal of the sequestrum, mosaic bone-cartilage grafts, or autologous chondrocyte grafts. At the same follow-up, mosaic grafts give better results than excision of sequestra. It may be useful to remove sequestra in a limited number of situations: if there is just a small area of osteochondritis, the lesion is old and partially healed, or the zone is non weight-bearing. For other lesions, we favor mosaic grafts. We still do not have enough follow-up to assess the long-term outcome with these mosaic grafts, but simple excision clearly favors osteoarthritic degradation. Can chondrocytes grafts be compared with mosaic grafts? Chondrocyte grafts have been used for very large lesions and have given results similar to mosaic grafts. It might also be possible to combine fixation of a loose fragment and a mosaic graft. LESSONS FROM THIS STUDY: 1) The prognosis of osteochondritis is better before than after fusion of the growth plate but the lesion does not always heal in children. 2) Presence of osteochondritis requires complementary anatomic and functional exploration to determine the stability and the vitality of the fragment. 3) Attention must be taken to perform transchondral perforations early enough, particularly in children. 4) Screw fixation is not always sufficient. The trophicity of the fragment and its blood supply must be improved. 5) Mosaic grafts are preferable to excision of the fragment. 6) Chondrocyte grafts will be more widely used in the future.