[Efficacy and tolerance of Algosteril (calcium alginate) versus Jelonet (paraffin gauze) in the treatment of scalp graft donor sites in children. Results of a randomized study]. / Evaluation de l'efficacité et de la tolérance d'Algostéril (compresse d'alginate de calcium) versus Jelonet (gaze paraffinée) dans le traitement du site donneur de greffe dermo-épidermique du cuir chevelu. Résultats d'un essai pédiatrique.

Split skin graft is frequently needed in the treatment of burned patients. Scalp is often free of burns. Due to its good skin quality and important surface, scalp is a very interesting skin donor site, specially in case of children. A controlled, randomised clinical trial was carried out in 10 French Plastic Surgery or Burns Units. It assessed the efficacy and the acceptability of calcium alginate dressing (Algosteril) versus paraffin gauze dressing (Jelonet) in the treatment of scalp donor sites in children. 67 children (mean age 54 months) entered the study, 34 in the alginate group and 33 in the control group. Follow-up visits were on day 2/d3, d5/d6, Day complete healing, d30 and d60 after surgery. The two groups were comparable on inclusion (demographic characteristics, burn nature and surface, donor site surface and thickness of split skin graft). The mean healing time was 10 and 11 days for Algosteril and Jelonet group respectively (ns). The quality of the newly formed tissue was estimated to permit a sooner skin reharvesting in the Algosteril group than in the control group (p = 0.003). Bleeding through dressing was significantly less important in the Algosteril group (p = 0.02). Changes were considered by investigators less painful with Algosteril on day complete healing (p = 0.0096). Hair growth is homogenous in both groups on day 30 and day 60 (ns). These results showed that scalp is a very interesting skin donor site and that Algosteril is of a real interest in donor site treatment.

[Pelvic osteotomies in children and adolescents]. / Les ostéotomies du bassin chez l'enfant et l'adolescent.

The main types of pelvic osteotomies in children and adolescents are reviewed. Osteotomies in the first group aim at reorienting the acetabulum: Salter's innominate osteotomy is widely used; its technique, possible drawbacks and indications are analyzed; double and triple osteotomies are then reviewed (Sutherland, Le Coeur, Steel, Tönnis and Trousseau) with their prerequisites, drawbacks and specific indications. A second group of osteotomies do not involve complete transsection of the hemipelvis; they are acetabuloplasties following the techniques described by Dega and by Pemberton, the indications of which are also presented together with their prerequisites. Last comes Chiari's osteotomy: it appears as a palliative operation, with limited indications in children and adolescents. Finally, the indications for pelvic osteotomies are reviewed, according to patient's age, anatomical status of the hip and underlying pathology. Unstable and dysplastic DDH hips may be treated by Salter's osteotomy, Pemberton's acetabuloplasty of triple pelvic osteotomy if the hip is mobile, well centered and congruous. The more simple Salter and Pemberton operations are to be preferred to triple osteotomy as long as they are indicated, i.e. until the age of 5 to 8 years. Established congenital dislocations may be treated using Chiari's osteotomy in cases where a reorientation osteotomy or acetabuloplasty is no longer indicated, provided the hip remains mobile. The indications for pelvic osteotomy in Perthes disease are analyzed, and the arguments for a pelvic rather than femoral osteotomy in some cases are presented. Pelvic osteotomies with the numerous techniques developed over the years, have been a major advance in the treatment of hip anomalies in children. In older adolescents, their indication must be balanced against those of hip reconstruction; they must anyway never make subsequent arthroplasty in adult age difficult or impossible.

[Recurrence or persistence of an osteoid osteoma: a case report]. / Redicive ou persistance d'un ostéome ostéoïde: une observation.

Recurrence of an osteoid osteoma treated by complete excision is thought to be very rare. Persistence of the lesion and reappearance of clinical and radiological signs have a more frequent occurrence, and are due to inadequate resection. Our case appears to be a true recurrence. It required no less than four operations first of these was probably not extensive enough. The second consisted of curettage of the osteoid osteoma after it had been exposed by abrasion of its cortical bone covering. The third and fourth resections were carried out under bone scan guidance and were controlled by postoperative radiography and computerised tomography. The uncertain aetiology of osteoid osteoma is one factor in the mysteriousness of this serial recurrence of what was apparently an ordinary osteoid osteoma. Such recurrence might be explained by an unknown persisting pathological environment.

Clinical examination and investigation of the cruciate ligaments in children with fibular hemimelia.

In this retrospective study of abnormalities of the cruciate ligaments in children with fibular hemimelia, 69 knees were clinically examined, of which 20 were further investigated by means of arthroscopy or nuclear magnetic resonance imaging (NMRI) for objective evidence of ligament lesions. The study allowed the type and incidence of cruciate ligament abnormalities found in this condition to be determined. The anterior cruciate ligament was affected (aplasia or hypoplasia) in 95% of cases and the posterior cruciate ligament in 60%. Although these lesions only rarely have functional consequences in such patients, pretreatment assessment should nevertheless include an active search for their presence to avoid subluxation of the knee during femoral lengthening, should this be the chosen approach.

Radiological study of severe proximal femoral focal deficiency.

Twenty-two hips in 20 children, all classified as Amstutz type 3 proximal femoral focal deficiency, were studied by means of plain radiographs, arthrograms (30), ultrasound examination (six), computed tomography (CT) scans (including five arthrographies with CT) and magnetic resonance imaging (MRI; nine). These investigations demonstrated that in 15 hips, the superior femoral epiphysis was mobile in the acetabulum, whereas in six others, it was fixed and fused to the acetabulum. In one case, it was impossible to prove whether the epiphysis was mobile or fixed. The key radiologic and other image features that allow these conclusions to be drawn are described. The therapeutic implications are important, as it would be pointless or harmful to attempt to consolidate the femoral neck or put it into valgus when the epiphysis is spontaneously fixed to the acetabulum.

Scoliosis and fused ribs. A case report.

STUDY DESIGN: This case report illustrates a scoliotic patient with congenital fusion of several ribs associated with a thoracic curvature. OBJECTIVES: To report the procedure used to correct scoliosis in association with congenitally fused ribs. SUMMARY OF BACKGROUND DATA: All cases of congenitally fused ribs reported in the literature are associated with malformed vertebrae. For this reason, the only proposed treatment for patients with progressive scoliosis is a spinal fusion. This report presents the first case of progressive scoliosis associated with fused ribs, but without vertebral malformation, that was managed by resection of these ribs. METHODS: When worsening of the thoracic scoliosis was observed from 30 degrees at 13 months to 44 degrees at 4 years, the three fused ribs were resected en bloc. No spinal fusion was performed. The spine was held in correction by a localizer cast for 3 months. RESULTS: Fourteen years after treatment, the spine is almost normal; thoracic and lumbar curves are 10 degrees. CONCLUSIONS: When malformed fused ribs are on the concave side of a progressive scoliosis with no vertebral malformation at the same level, resection of these ribs is probably an efficient and sufficient method of treatment.

Ilizarov technique in the treatment of congenital pseudarthrosis of the tibia.

This study analyzes the risks and benefits of Ilizarov's technique in congenital pseudarthrosis of the tibia (CPT). This was a retrospective review of 14 patients treated between 1985 and 1993 for CPT, by using Ilizarov's technique. In 12 cases, this technique was used after failure of previous surgical treatment. Realignment, end-to-end compression, and leg lengthening were undertaken in all the cases, without excision of the pseudarthrosis site. The mean fixation duration was 7.8 months. Union was achieved with the initial treatment in seven cases. Bone grafting was used in six of the seven remaining cases and achieved bone healing in three of them. Refracture occurred in one case, and ended with nonunion. At 3.5-year average follow-up, the tibia was united in nine cases. We found that the best indications for Ilizarov's technique in CPT were the normotrophic and hypertrophic types of pseudarthrosis (Apoil II), after the age of 5 years. Secondary massive bone grafting is to be considered in some cases. The major disadvantage of this method is the lack of excision of the pseudarthrosis site. Even after healing is achieved, the bone remains dystrophic and fragile and necessitates a permanent protective orthosis, until the end of bone growth.

[Irreductible congenital dislocation of the hip at birth]. / Luxation congénitale de hanche irréductible à la naissance.

BACKGROUND: Rare congenital dislocation of hip (CDH) (0.03 for 1,000 births) are irreducible at birth; they are named teratologic in literature. However some of them are isolated without any pathological context, having a postural origin or due to an underlying disease. PATIENTS: Seventeen dislocated hips, irreducible at birth, were seen in 12 infants and included in this study. Clinical examination of these neonates was normal with the exception of signs of CDH. Postural abnormalities such as pes calcaneus, genu recurvatum, torticolis were seen in ten infants but none of the 12 had any manifestation of neurologic, dystrophic or malformative disease. However, manifestations of a disease able to explain the CDH such as congenital myopathy, cutis laxa, cortical atrophy, Klinefelter syndrome, appeared within the following months in four infants. Treatment of these CDH started in every case by an attempt of reduction by continuous traction and was efficient in eight cases. A redislocation occurred for four hips and this treatment was uneffective for five hips. Finally seven hips had to be treated by open reduction. Reduction was maintained for nine hips after closed treatment (one of them after a redislocation and a second time of orthopaedic treatment). One hip is still dislocated after failure of closed treatment. Stabilisation of the reduction was necessary by pelvic and/or femoral osteotomy in majority of cases. CONCLUSIONS: Morphological modifications of hip established from X-rays and during the surgical procedure are rather related to the age of the dislocation making inappropriate the term "teratologic". The irreducible and isolated CDH can be postural in origin but as well due to a disease whom manifestations will appear lately. Their treatment, orthopaedic or surgical, is difficult and the results often disappointing.

[Contralateral preventive screwing in proximal femoral epiphysiolysis]. / Vissage préventif controlatéral dans l'épiphysiolyse fémorale supérieure.

PURPOSE: The incidence of bilaterality in slipped capital femoral epiphysis (SCFE) ranges, in the literature, from 19 per cent to 80 per cent. The role of contralateral pinning is to prevent late slipping of the femoral epiphysis and its complications. The purpose of this study is to assess the usefulness of routine preventive contralateral pinning in SCFE, and to evaluate its complications. MATERIAL AND METHODS: We reviewed retrospectively 74 consecutive patients treated for unilateral SCFE by associated routine preventive contralateral pinning. The age at surgery ranged from 10 years and 6 months to 16 years and 10 months. The osteosynthesis was achieved by a single cannulated holothreaded screw with a cross grooved head, with or without the use of washers. RESULTS: An accidental pin penetration was noted in 4 cases. The epiphyseal position of the screw was satisfactory in 56 cases. The patient was allowed to walk the second or third day after surgery with the use of crutches. All our patients were reviewed after the end of squeletal growth. The follow-up ranged from 2 to 12 years and 8 months. The age at which the patient was last seen ranged from 15 years and 7 months to 27 years. Two major complications were noted: a femoral fracture at the level of the screw penetration in one case, and secondary slipping of the epiphysis after premature removal of the screw in two cases. The removal of the screw was considered to be very difficult in 10 cases. A relative overgrowth of the greater trochanter was noted in 8 cases, and was of no clinical significance. No infection was noted. At last follow-up, the shape of the femoral head and the function of the hip were normal in all cases except for one hip where severe coxa vara developed because of a secondary slip after premature removal of the screw. DISCUSSION: There is a lot of controversy about the real necessity of routine preventive contralateral osteosynthesis in SCFE. In our experience this surgery succeeded in reducing the incidence of secondary contralateral slipping. The two cases in our series could have been prevented by an accurate timing of screw removal. The complications of this procedure are rare, and it could be done during the same operative time as the SCFE side's. The only case of femoral fracture was secondary to a violent car accident. CONCLUSION: The routine prophylactic controlateral osteosyntheis in SCFE, using a single screw is a safe procedure and allows to reduce the incidence of bilaterality.

[Contribution of Ilizarov's equipment in the treatment of congenital pseudarthrosis of the lower limb]. / Apport du matériel d'Ilizarov dans le traitement de la pseudarthrose congénitale de jambe.

INTRODUCTION: Risks and benefits of using Ilizarov apparatus in the treatment of congenital tibial or fibular pseudarthrosis (CTFP) are presented in this retrospective study. MATERIALS AND METHODS: We reviewed with an average follow-up of 3 years and 4 months, the outcome of twenty consecutive patients treated between 1985 and 1993, for a CTFP using the Ilizarov apparatus. Sixteen patients were treated for non union of both tibia and fibula, 1 patient for an isolated non union of the fibula, and 3 patients for correction of a previously treated, malunited pseudarthrosis. The apparatus was used in four different ways: Realignement, end to end compression, and leg lengthening in 14 cases, Simple external fixation in association with another method of treatment in 2 cases, Progressive correction of malunion in 3 cases, Progressive diaphyseal reconstruction in 1 case (fibula). RESULTS: The mean fixation duration was 7.3 months. Union was achieved with the initial treatment in 11 out of 20 cases (including the 3 cases of malunion correction). Bone grafting was used in 7 out of the 9 remaining cases, and led to bone healing in 3 of them. Five complications were encountered: deep infection in 1 case, repeated stress fracture in 1 case, repeated fracture of the pins in 1 case, malunion in 6 cases, and less than 3 cm leg length discrepancy in 4 cases. DISCUSSION: Ilizarov external fixator is an efficient solution for many cases of CTFP, in which healing did not occur with other methods of treatment. The best indication for its use are the normotrophic and the hypertrophic types of non union (Apoil II), after the age of 4 or 5. Secondary massive bone grafting is to be considered in some cases, since it can either achieve bone union or strengthen it. The major disadvantage of this method is the lack of excision of the dystrophic tissue at the non union site. So, even after the non union is healed, the bone remains dystrophic and fragile, and necessitates a permanente protective orthosis, until the end of bone growth.

[Congenital convex talus. Methods and results of a single-stage surgical correction]. / Le pied convexe congénital. Technique et résultats de la correction opératoire en un seul temps.

PURPOSE OF THE STUDY: The aim of this study was to emphasize the anatomical particularities of congenital vertical talus. We propose a one stage operative procedure adapted to the deformities. MATERIALS AND METHODS: A retrospective study of 24 children with congenital vertical talus was conducted. An etiology was observed in 58 per cent of cases and 42 per cent were considered as idiopathic. From a radiological analysis of 39 feet, we precise the anatomical particularities. We used anteroposterior and lateral X-ray and lateral stress views with maximal plantar and dorsal flexion. Most of the lesions were localized in the midtarsal joint. The irreducibility of the talonavicular dislocation is the predominant lesion. It is usually associated with a disorientation of the cubocalcaneal joint. The articular surfaces are disorganized with a dorsal orientation. There is a variable amount of equinus deformity in the hindfoot. However the talocalcaneal divergence angle is nearly normal. The forefoot is most of the times in eversion but sometimes in inversion. PROCEDURE: All children were treated initially by physiotherapy. We recommend operative treatment for them between one to two years old. After a soft tissue release, the talonavicular dislocation and the hind foot equinus deformity is reduced simultaneously. The subtalar joint is respected and not opened. Retracted tendons may be an obstacle to the reduction. They must be lengthened if necessary especially the Achilles tendon, the peronei, the extensors and the tibialis anterior. Reduction is maintained by a K wire transfixing the midtarsal joint. RESULTS: Clinical results were difficult to evaluate. Out of 24 operated feet, a satisfactory outcome had been achieved in 15 feet. All were plantigrad and 18 had a good cosmetically aspect. The only bad result concerned an old case which was not operated by this technique. DISCUSSION AND CONCLUSION: Conservative treatment is usually unsuccessful in congenital vertical talus. Numerous procedures have been advocated for the surgical correction of this deformity. Some authors advised excision of the navicular, full open peritalar release or extraarticular talocalcaneal arthrodesis. These are often extensive procedures and most are performed in two stages. Recently, one stage operative procedure was proposed. It allows a good correction with the respect of the subtalar joint and a lower risk of talus avascular necrosis. Furthermore it is more adapted to the deformity with a less extensive scar and a better respect of the anatomy.

Osteoid osteoma or osteoblastoma of the cervical spine in relation to the vertebral artery.

Osteoid osteoma or osteoblastoma of the cervical spine require complex therapeutic solutions in cases in which there is proximity to the vertebral artery. We describe four such cases. Generally, resection was efficacious and without recurrence, but twice the vertebral artery had to be sacrificed. Although we did not find any serious neurological complication, we concluded that a simple sacrifice of one of the vertebral arteries is not acceptable, principally because of the importance and variability of the unknown radiculomedullary branches of the vertebral artery. We discuss the therapeutic strategies for treating these lesions, namely preoperative investigations, surgical approaches, and vascular control.

[Neurologic complications of surgery of the spine in children]. / Complications neurologiques de la chirurgie du rachis chez l'enfant.

Neurological deficiency can occur during or after spinal surgery. The most severe complications are seen after instrumental correction for scoliosis or kyphosis. Regression of paraplegia, paraparesia and Brown-Sequard syndrome is never a certainty and usually incomplete. Preoperative manoeuvres and evoked potentials do not provide absolute security and metal instrumentation should always be used prudently. The main risk factors are vertebral malformation, major kyphosis, preoperative signs of neurological deficit, excessive correction and double anterior and posterior access. Finally, the canal is poorly vascularized from T4 to T8 or T9 which can raise further problems. Cordal deficiency during or following almost always requires removal of the metal implant, and exploration of the canal possibly with MRI. Injury include direct contusion of the spinal cord, devascularization and compressive haematomas. The frequency of neurological complications is currently about 1% and only extreme prudence and knowledge of causes can reduce this rate.

[Treatment of limb deformities by the Ilizarov method]. / Traitement des déformations des membres par la méthode d'Ilizarov.

INTRODUCTION: The numerous possibilities for adapting the Ilizarov apparatus allows the progressive correction of complex angular deviations, for which flat apparatus are sometimes difficult to adapt and this report describes our experience using the Ilizarov apparatus to treat axial limb deformities. MATERIAL AND METHODS: A total of 48 patients (22 girls and 26 boys aged between 2 and 18 years-old) suffering from 58 angular deformities were treated with an Ilizarov device. 40 of the deformities involved bones: 22 tibias, 13 femurs and 6 radius. The remaining 18 deformities involved joints, (17 knees and 1 elbow), 12 were total ankylosis and 6 were flexion contractures. 31 of the cases involved an isolated deformity (16 bones and 16 joints) and 27 were associated with other orthopedic problems. The cause of the deformities were either malformation or infection in most cases. In 39 cases the angular deformities were deviations in a single plane: 13 in two planes and 6 déformities were complex, involving deviation in all three planes. Correction was progressive in 49 cases and immediate in 9 cases. Unequal limb length was treated in 21 cases: 19 of these were caused by bone deformity. The apparatus should cover the entire bone segment to be corrected, from metaphysis to metaphysis. When the deformity is close to a joint, the joint should be bridged so as to stabilize the brace. The fastening of the sides of the deformity involves a maximum of three pins in two different planes. The apparatus must be absolutely rigid so as to avoid any lateral slipping or any movement of the rings relative to the segments of the limbs. The two parts of the apparatus fixed on either side of the deformity should be linked by two groups of three threaded rods with articulations at the ends. When the correction is in a single plane, it is effected around the axis formed by two threaded rods at the point of the deformity. When the deformity is major, 90 degrees or more, the rings tend to shift under the strain, and this leads to a loss of correction and cutaneous problems on the concave face. This may be avoided by fixing threaded rods to the ring, perpendicular to the plane of the deformity. For knee flexion contractures, the rods should be connected to the ring where it crosses the frontal plane passing through the femoral diaphysis. RESULTS: 48 angular deviations were completely corrected. In 10 cases the deformity persisted, but was less than 20 degrees. The deformity reoccurred in 6 of the children: in 3 cases due to the persistence of muscular imbalance, in two cases by assymetric growth, in the other case by plastic deformation on the insufficiently mineralized regenerated bone tissue formed during lengthening. In one case, the common, motor and sensor peroneal nerve was paralyzed, complicating the correction of an anterior dislocation of the knee. The paralysis occurred at the end of the correction and recovery began after 6 months. One 10 year old child, suffering from nail patela syndrome, was left with a completely immobilized elbow after treatment of a webbed, 100 degrees flexion contracture. A total of 9 epiphyseal separations (Salter I type) occurred during the correction of severe deformities, with little or no displacement, all occurred around the knee. These epiphyseal separations did not interfere with the treatment of the angular deviations in three cases, however, advantage was taken of these events to effect the intended lengthening of the bone. DISCUSSION: The Ilizarov method for correcting joint ankylosis is difficult to perform, and depends on a detailed knowledge of the apparatus and braceing system, and requires rigourous installation of the pins, ring, joints and rods. Whatever the position of the two rings in relation to each other, it is always possible to link them by a system which can be adjusted. This is not possible with other external braces which have only a single plane.

[A rare cause of bone pain in children: primary hyperparathyroidism caused by adenoma]. / Une cause rare de douleurs osseuses chez l'enfant: l'hyperparathyroïdie primaire par adénome.

BACKGROUND: Primary hyperparathyroidism is rare in children and adolescents. Bone changes may produce pain in the back or extremities, but this is rarely the first symptom of the disease. CASE REPORT: A 13 year-old girl suffered from pain in the back and lower extremities. Progressive bilateral genu valgum appeared. One year later, she became lame because of the deformity. ECG showed cardiac arrhythmia with atrial extra systoles. The serum calcium concentrations were 3.36 and 3.8 mmol/l, phosphate 0.76 mmol/l and alkaline phosphatases 6,612 U/I (N: 90-300). Urinary excretion of calcium was 17 and 26 mg/kg/day and the renal tubular reabsorption of phosphate was 77%. Radiological studies revealed resorption of subperiosteal bone, best seen along the margins of the phalanges, demineralization of the skull vault, bilateral coxa vara and zones of calcification on knee metaphyses. The serum concentration of parathyroid hormone (PTH) was 1,066 pg/ml (N: 10-55) and that of 1-25(OH)2D3 was 125 ng/ml (N: 20-80). Ultrasonography showed a heterogeneous mass, 23 x 15 mm, suggesting a parathyroid adenoma. This adenoma was independent of the left inferior parathyroid. It was removed and the biochemical findings gradually returned to normal. Bone demineralization also disappeared and the knee deformities were surgically corrected 9 months later. CONCLUSIONS: Bone changes may occasionally cause severe pain, indicating demineralization and hypercalcemia: hyperparathyroidism is one cause of such changes.

Lumbosacral agenesis. Three cases of reconstruction using Cotrel-Dubousset or L-rod instrumentation.

Three patients with lumbosacral agenesis underwent surgery to lock the lumbopelvic instability. All three patients had an unstable sitting position and a kyphotic bearing that impaired intestinal transit or hampered further colostomy or ureterostomy. Luque instrumentation with iliac fixation performed according to Galveston was used in one patient. Cotrel-Dubousset instrumentation was used for the two other patients. Autografts plus allografts provided sufficient bone for fusion without requiring lower leg amputations. Increased hip flexion was obtained after pelvic stabilization, but knee flexion contracture remained the same. All patients showed improved intestinal transit or decreased urinary infections, and two patients attained a stable sitting position without aid.

[Supracondylar fractures of the humerus associated with ipsilateral fractures of the forearm]. / Fracture supra-condylienne de l'humérus associée à une fracture homolatérale de l'avant-bras chez l'enfant.

We report 20 cases of ipsilateral supracondylar elbow fracture and forearm fracture in childhood. The mean follow-up was 20 months. For an analysis of the results, we used a global rotation of the upper limb. We appreciated the motion and the carrying angle of the elbow and the wrist. 15 cases were very good or good; there were 4 cubitus varus without functional impairment and 1 failure after one open Monteggia fracture. The therapeutic strategy is discussed. If one does not want to increase the damage to periosteum in the elbow during the forearm reduction, one must first reduce the supracondylar fracture and fix it by 2 pins like in Judet procedure. Then, the forearm fracture should be treated conservatively.

[Spinal deformities in Marfan disease]. / Déformations rachidiennes de la maladie de Marfan.

Spinal deformities are frequent in Marfan's disease. 37 patients were examined at the average age of 11 years. 32 showed a spinal deformity. The treatment of the spinal deformity was a brace in 15 cases, surgery in 16 cases (including 5 cases after brace-failure). 7 cases were just followed-up without treatment. Bracing was efficient only for mild curves, this treatment was satisfying 4 times out of 11 with adequate follow-up. The surgical treatment in 16 cases was a posterior fusion twice associated with anterior fusion. We used the same technique as for idiopathic scoliosis with Harrington instrumentation 5 times, Harrington with sublaminar wires 4 times and Cotrel-Dubousset instrumentation 7 times. The correction of scoliosis was achieved in 48.2 per cent. The use of segmental instrumentation compared with the use of the Harrington instrumentation can explain the small number of non unions and the improvement of the lateral spinal balance. We did not note any cardiovascular complication during or early after the operation. Aortic lesions were responsible of one death in the long term, three patients went through a surgical replacement of aortic valves or the aorta.