Spontaneous recovery of experimental valgus deformity in lambs.

INTRODUCTION: Angular deformity in the growing skeleton of animals, especially in the radius and ulna, is occasionally seen in clinical practice. The mechanism of spontaneous correction of these angular deformities however remains to be elucidated. The purpose of our experiment was to explore the ability of a growth plate to correct an induced valgus deformity, and to study the mechanism of correction. METHODS: Before beginning the study, valgus deformity of the distal radius had been induced in lambs by the application of a device that causes asymmetrical compression of the growth plate. The study began after removal of the device and spontaneous correction of the induced deformity was observed weekly for 20 weeks. The angles of the deformity and longitudinal growth on the medial and lateral portions of the growth plate were respectively measured on craniocaudal and mediolateral radiographs. RESULTS AND CONCLUSIONS: Spontaneous correction of the valgus deformity occurred during the first 16 weeks. It resulted from asymmetrical growth characterised by restricted activity of the medial portion of the growth plate (14.8%) in comparison to the lateral portion of the experimental radius, and also in comparison to the medial portion of the control radius.

[Arthroscopic anterior capsular release in medial contracture of the shoulder secondary to brachial plexus birth palsy. Preliminary results]. / Arthrolyse antérieure de l'épaule sous arthroscopie dans les séquelles de paralysie obstétricale du plexus brachial. Résultats préliminaires.

PURPOSE OF THE STUDY: Retraction of the shoulder in internal rotation is observed in 25% of children with brachial plexus birth palsy (C5, C6 +/- C7). Early bone and joint deformities affecting the glenohumeral joint are the consequences. The stiff internal rotation requires surgical release which can involve the capsule and ligaments, muscles, or both. Internal release can be combined with muscle transfer to improve active external rotation. We report the results obtained with arthroscopic anterior capsular release combined with latissimus dorsi transfer. MATERIAL AND METHODS: From 1999 through 2006, fourteen children with a stiff shoulder in internal rotation secondary to brachial plexus birth palsy were managed in our unit. All had recovered biceps function six months after surgery. The glenohumeral dysplasia was analyzed on the preoperative magnetic resonance imaging. Pre- and postoperative passive external rotation (RE) were measured with the arm along the body and at 90 degrees elbow flexion. Internal rotation was measured using the Mallet score (hand-back test). Combined active abduction antepulsion was measured when the child was playing. Mean age at surgery was three years six months. Arthroscopic internal release was performed for eight children. All had an associated latissimus dorsi transfer. RESULTS: Among the 14 children managed in the unit, arthrolysis was not be performed in six, either because of the lack of an adequate electrode (two patients) or because the child presented posterior glenohumeral dislocation making it impossible to introduce the optic channel (four patients). Arthroscopic anterior release was performed for the eight other patients. These eight patients were reviewed at a mean three-year follow-up. Passive external rotation was improved, with a mean gain of 60 degrees with no recovery of passive internal rotation. The abduction antepulsion movement was also improved, mean gain 90 degrees . DISCUSSION: A stiff shoulder in internal rotation can develop during the first two years of life. Several techniques have been proposed for internal release. The origin of the progressive limitation of passive external rotation remains a subject of debate. Is it due to retraction of the internal rotators, or to capsule-ligament retraction, or both? In 1992, Harryman et al. demonstrated the role of the capsule and the coracohumeral ligament in limiting external rotation. Consequently, we have opted for early release (less than two years of age) using an arthroscopic method limited to the capsule and ligaments. Our results for passive external rotation are comparable to those reported by others. However, this technique enables preserved mobility for internal rotation. CONCLUSION: Arthroscopic anterior release limited to the capsule and the ligaments is an effective, minimally invasive technique. Leaving the internal rotator muscles intact preserves internal rotation of the shoulder and reduces the risk of anterior instability.

[When doors slam, fingers jam!]. / Quand les portes claquent, les doigts craquent!

AIM: Epidemiological analysis in a universitary paediatric emergency unit of children admitted after accidental injuries resulting from fingers crushed in a door. MATERIAL AND METHODS: Prospective, descriptive cohort study from September 6th, 2004 to July 1st, 2005 included all children admitted for finger injuries crushed in a non-automatic door. EXCLUSIONS: included accidents due to automatic doors, toy's or refrigerator doors, families who refused to participate to the study or families who had left the waiting area before medical examination. Collected data were patient and family characteristics, accident characteristics and its management. RESULTS: Three hundred and forty children affected by 427 digital lesions were included. The mean age was 5.5+/-3.8 years (range 4 months - 15.5 years). Male/female ratio was equal to 1.2: 1. Fifty-eight percent of patients belonged to families composed of 3 or more siblings. Ninety-three per cent of families came to hospital within the first 2 hours after the accident (mean delay 99+/-162 min, median range 54 minutes). Location of the accident was: domestic (62%, at home (64%)), at school (17%). Locations within the home were: the bedroom (33%), bathroom and toilets (21%). An adult was present in 75% of cases and responsible for the trauma in 25% of accidents, another child in 44%. The finger or fingers were trapped on the hinge side in 57% of patients. No specific safeguard devices were used by 94% of families. Among victims, 20% had several crushed digits; left and right hand were injured with an equal frequency. The commonest involved digits were: the middle finger (29%), the ring finger (23%). The nail plate was damaged in 60% of digital lesions, associated with a wound (50%), a distal phalanx fracture (P3) (12%). Six children had a partial or complete amputation of P3, 2 children a lesion of the extensor tendon, 1 child had a rupture of the external lateral ligament. Three percent of children required an admission to the paediatric orthopaedic surgery unit. Post-traumatic pain was mainly limited to the first 48 h (64%). Early complications included: 16 cases of infected injuries, 3 cases of pulpar necrosis. The total cost of hospital care was 71,500 euros, the average cost for hospitalised patient equal to 2100 euros and for ambulatory cases equal to 141 euros; the annual cost was estimated at 81,600 euros. CONCLUSION: Associated with potentially serious digital injuries, functional or inesthetic sequelae, this painful experience still remains too frequent in toddlers for a home accident that could be often prevented by the acquisition of specific protective doors devices and for a reasonable cost compared to the cost of hospital care.

In situ pinning in slipped capital femoral epiphysis: long-term follow-up studies.

BACKGROUND: Management of moderately displaced slipped capital femoral epiphysis (SCFE) is debated, mostly because of the risks related to open reduction on one hand, and subsequent evolution toward femoroacetabular impingement (FAI) on the other. METHOD: All SCFE cases treated with in situ fixation (ISF) and a minimum of ten years of follow-up beyond skeletal maturity were analysed in a retrospective multicentre study. Coxometry parameters were measured. Long-term results of ISF were meanwhile analysed at our Institution. RESULTS: A total of 222 patients were included. Patient reported outcome measurements were related to the severity of the initial slip. It suggested a 35.5° threshold for slip angle beyond which FAI was more frequent. Only slight remodelling at the head-neck junction is to be expected. CONCLUSION: Based on these findings, it seems reasonable to perform ISF only in SCFE with a slip angle below 35°.

Development of the clinical tibiofemoral angle in normal adolescents. A study of 427 normal subjects from 10 to 16 years of age.

We measured the clinical tibiofemoral (TF) angle and the intercondylar (IC) or intermalleolar (IM) distance in 427 normal European children (212 male and 215 female) aged from 10 to 16 years. In our study, girls had a constant valgus (5.5 degrees) and displayed an IM distance of < 8 cm or an IC distance of < 4 cm. By contrast, boys had a varus evolution (4.4 degrees) during the last two years of growth and displayed an IM distance of < 4 cm or an IC distance of < 5 cm. Values above these for genu varum or genu valgum may require careful follow-up and evaluation.

Assessment of hindfoot deformity by three-dimensional MRI in infant club foot.

In 12 infants aged under 16 months with unilateral club foot we used MRI in association with multiplanar reconstruction to calculate the volume and principal axes of inertia of the bone and cartilaginous structures of the hindfoot. The volume of these structures in the club foot is about 20% smaller than that in the normal foot. The reduction in volume of the ossification centre of the talus (40%) is greater than that of the calcaneus (20%). The long axes of both the ossification centre and the cartilaginous anlage of the calcaneus are identical in normal and club feet. The long axis of the osseous nucleus of the talus of normal and club feet is medially rotated relative to the cartilaginous anlage, but the angle is greater in club feet (10 degrees v 14 degrees). The cartilaginous structure of the calcaneus is significantly medially rotated in club feet (15 degrees) relative to the bimalleolar axis. The cartilaginous anlage of the talus is medially rotated in both normal and club feet, but with a smaller angle for club feet (28 degrees v 38 degrees). This objective technique of measurement of the deformity may be of value preoperatively.

Obstetrical brachial plexus palsy. Prediction of outcome in upper root injuries.

Thirty obstetrical brachial plexus palsies involving the upper roots were retrospectively reviewed. There were 20 C5-C6 palsies and ten C5-C6-C7 palsies in which recovery of C7 occurred by the end of the first month. Recovery of elbow flexion at 3 months, C7 involvement and high birthweight were the best early predictors of outcome, but all were unreliable when used separately. In combination, recovery of elbow flexion and birthweight predicted the final outcome reasonably satisfactorily, particularly when elbow flexion at 9 months, and not 3 months was considered (risk of error = 13%). Brachial plexus reconstruction may therefore be justified when there was initial C7 involvement associated with increased birthweight and poor elbow flexion at 6-9 months.

Long-term effects on tibial growth after intraosseous infusion: a prospective, radiographic analysis.

BACKGROUND: Evaluate, by radiographic analysis, tibial growth after an intraosseous infusion (IOI) in a pediatric population. METHODS: We performed a prospective simple blind study, between January 1, 1994, and July 1, 2001, which included pediatric patients who needed an intraosseous trocar in emergency situations. During the follow-up, roentgenographs were performed. On each radiologic view, different measurements were carried out: anterior and lateral tibial length, anterior and lateral width at 2 diaphyseal levels. We compared the anterior length values to those published in the Anderson et al tables. When only one tibia was punctured, the mean measurements were compared with the control leg measurements using a paired t test. RESULTS: The initial population included 78 patients. Of these 78 subjects, 42 died, 10 families could not be contacted, and one refused to participate. Two children were excluded because they had other conditions that could influence tibial growth. The study included 23 children. The puncture site was the proximal tibia. The mean age was 18.6 months at the time of IOI, the mean time of infusion was 5 hours, and the mean perfused volume was 225 mL. The mean radiologic follow-up time was 29.2 months. When compared with the Anderson et al tables, all the anterior length values were within the 95% confidence interval. For the other measurements, the statistical analysis showed no significant difference between punctured and control legs. CONCLUSION: There is no long-term effect on tibial growth after an IOI when the IO trocar is properly placed.

Imaging evaluation of subluxation in Legg-Calvé-Perthes disease: magnetic resonance imaging compared with the plain radiograph.

The aim of the study was to evaluate the advantages of magnetic resonance imaging (MRI) in determining subluxation in Legg-Calvé-Perthes (LCPD) disease. Twenty-six patients with unilateral LCPD received 33 MRI and plain radiographs. For each patient, acetabulum head index (AHI) was measured on both hips (affected and unaffected) in a blinded fashion. Measurements were made from the cortical bone margin on the plain radiograph and from the cartilaginous surfaces on MRI. On the unaffected side AHI was 92.8% on the plain radiograph and 85% on MRI. On the affected side, AHI was 87% on the plain radiograph and 77% on MRI. These differences were statistically significant. With regard to the unaffected side, the femoral head should be considered subluxated if AHI is less than 86% on the plain radiograph and less than 77% on MRI. On the affected side, in 14 cases the femoral head was well-contained on both the plain radiograph and MRI. In 11 patients the femoral head was subluxated both on the plain radiograph and on MRI. In 8 patients the femoral head was well-contained on the plain radiograph but subluxated on MRI. This was due to thickening of the cartilaginous portion of the femoral head, which was clearly seen on MRI. MRI appeared to be more sensitive in determining the subluxation of the femoral head during the active phase of LCPD.

Congenital pseudarthrosis of the clavicle and thoracic outlet syndrome in adolescence.

A 15-year-old girl with thoracic outlet syndrome associated with congenital pseudarthrosis of the clavicle was examined. The indication for treatment of congenital pseudarthrosis of the clavicle is discussed.

Natural course of osteochondritis dissecans in children.

Results are reported from an absence of physiotherapic, orthopaedic, or surgical treatment in 31 cases of osteochondritis dissecans in 24 children. The mean age at diagnosis was 11 years and 4 months, and all the children were suffering from pain for an average of 3 months. None of these children were treated, except for instructions to discontinue involvement in sports activities until their pain had disappeared. In all cases pain disappeared, and these children have all returned to their former activities. According to x-ray findings, 30 lesions disappeared totally, although there was one case of a loose body. As a result, absence of treatment is recommended for osteochondritis dissecans in children.

[Imaging of the hip in healthy children in MRI: evaluation of the acetabular coverage]. / Imagerie de la hanche de l'enfant sain en IRM: évaluation de la couverture cotyloïdienne.

PURPOSE: To define with MR imaging a reference value for acetabular coverage on coronal and sagittal images for a population of healthy children. MATERIALS AND METHODS: 36 children (72 hips) where prospectively studied over 1 year. T1-weighted spin-echo images in both coronal and sagittal planes were obtained. Slice thickness was 4 mm. Measurement of acetabular coverage (AHI: Acetabular-Head Index) was made in both planes with two different landmarks: bone and cartilage. Study of the evolution with age was made. RESULTS: The acetabular coverage is symmetrical and decreases with age. Its measurement is reproducible. CONCLUSION: This study shows that measurement of acetabular coverage (AHI) is easily obtained at MR imaging and is reproducible. We suggest 83 (mean 1SD) as the inferior limit for AHI based on cartilage measurements. We introduce sagittal values, never published. We believe that MR, by its ability to demonstrate the cartilaginous surfaces, will play a major role in the true understanding of the anatomical relationship between the femoral head and the acetabulum.

[Topographic and developmental study of primary osteochondritis of the hip by x-ray computed tomography]. / Etude topographique et évolutive de l'ostéochondrite primitive de la hanche par la tomodensitométrie.

The authors have studied 40 normal hips and 69 hips affected by Perthes' disease by computerised axial tomography. A classification proposed into three groups according to the extent of epiphyseal involvement. Type A comprises peripheral and limited abnormalities. Type B is concerned with more or less extensive central necrosis with an unaffected posterior area. Type C comprises involvement of the whole epiphysis. This classification allows a prognosis to be made. Type C patients were sub-divided into two groups--before and after 5 years of age. It was only in the latter group that excentration was observed. The authors note the considerable advantage of computerised axial tomography in the assessment of the degree of excentration.

[Experimental study of a growing acetabulum shelf (vascularized graft)]. / Etude expérimentale d'une butée cotyloïdienne en croissance (greffon vascularisé).

The author has operated on 50 immature rabbits to perform a vascularised transplantation of the growing iliac crest to replace the rim of the acetabulum. Vascularity was preserved through the vascular pedicle and there was no need for vascular anastomosis. The results were assessed radiologically and by histological studies. The subsequent growth of the transplanted epiphysis could be illustrated in 15 out of 16 cases. The growing shelf had the advantage of good adaptation to the shape of the femoral head and produced a satisfactory physiological result.

[Fatigue fracture of the patella in cerebral palsy (author's transl)]. / Les fractures de fatigue de la rotule chez l'infirme moteur d'origine cérébrale.

Amongst approximately 1 500 spastic children under treatment, the authors have seen three cases of fatigue fracture of the patella. One patient was spastic and two others were athetotic. The fatigue fractures can be explained by a flexed knee gait aggravated by a contracture of the hamstring tendons. No fracture was seen in patients treated by Egger's operation. It is concluded that this procedure both prevents and cures fatigue fracture of the patella.

[Value of the study of somatosensory evoked potentials during surgical correction of scoliosis associated with syringomyelia. Apropos of 4 cases]. / Intérêt de l'étude des potentiels évoqués somesthésiques au cours de la correction chirurgicale des scolioses associées à une syringomyélie. A propos de quatre observations.

PURPOSE OF THE STUDY: The presence of a syringomyelia cavity increases the rate of neurological complications on the course of surgical treatment of scoliosis. We have evaluated the results of monitoring of somatosensory evoked potentials (SEP) in these situations. MATERIAL AND METHODS: Four patients presenting a scoliosis associated with syringomyelia have been operated through a posterior-approach with CD instrumentation. SEP monitoring was performed pre and intraoperatively. We studied the latency and the amplitude of P40. RESULTS: Preoperative SEP showed in all cases posterior spinal cord involvement (even without clinical manifestations). During monitoring, we noted in one case no variation. In one case a flattening of the response with normalisation within 5 minutes. In two cases a persistent flattening with normalisation within 10 and 15 minutes following modification of the instrumentation. In all cases, postoperative neurological status was identical to preoperative one. DISCUSSION: Preoperative SEP can make the diagnosis of posterior spinal cord involvement even when clinical status is normal. The extent of the preoperative SEP abnormalities may preclude the risk of intraoperative neurological complications. Intraoperative SEP can be performed with the same anesthetic protocol and the same technique used when operating idiopathic scoliosis. The results seem reliable. When alteration occur as for idiopathic scoliosis alteration of the amplitude appears earlier than alteration of the P40 latency. Restoration of normal responses appears later than in idiopathic scoliosis. CONCLUSION: SEP monitoring should diminish the risk for neurological complications in the course of surgical treatment of scoliosis associated with syringomyelia.

[Surgical treatment of dislocations and subdislocations of the hip in patients with cerebral palsy by femoral and pelvic osteotomy]. / Le traitement chirurgical des luxations et subluxations de hanche chez l'IMC par ostétomie fémorale et pelvienne.

Fifty-one skeletally immature cerebral palsied (C.P.) children with 70 subluxated or dislocated hips were treated by conservative methods: femoral osteotomy (65 hips), pelvic osteotomy (52 hips) and arthrotomy when necessary (19 cases). 31 children were less than 10 years of age when operated on (mean 6 years, 6 months), 20 children were more than 10 years of age (mean 13 years, 13 months); mean follow-up was 4 years. Reduction and coverage were achieved and maintained in all patients, except for 6 redislocations: a pelvic obliquity was neglected in 3 cases; femoral shortening was not performed in 2 cases. Post-operative course was difficult in eldest patients with pain and stiffness but functional result was acceptable at follow-up in all cases except redislocations. Open reduction was related to a higher rate of postoperative rehabilitation problems. Modeling of previously deformed femoral heads and improvement of hip mobility were consistently seen at last follow-up, except for 3 redislocations. It is concluded that conservative methods are quite advisable in CP children and adolescents. Hip reduction should be preferred to femoral resection even in adolescent.

[Somatosensory evoked potentials during surgery of scoliosis: significance of epidural recording]. / Potentiels évoqués somesthésiques au cours de la chirurgie de la scoliose: intérêt du recueil épidural.

PURPOSE OF THE STUDY: To evaluate the usefulness of the epidural recording in scoliosis surgery in children or young adults. MATERIAL AND METHOD: We used somatosensory-evoked potentials in 60 children or young adults in surgical treatment of scoliosis. Somatosensory-evoked potentials were elicited and recorded using a standard method recording of cortical P40 and subcortical P27, simultaneously with the monitoring of spinal cord function using epidural electrode to record the ascending somatosensory volley (by tibial nerve stimulation) at a high thoracic level. RESULTS: The use of subcortical and epidural recording sites for the somatosensory-evoked potentials indicated that a reliable response could be obtained in 96 p. 100 of the patients. Cortical somatosensory-evoked demonstrated a 48 p. 100 false positive rate. DISCUSSION: Epidural recording in scoliosis surgery is safe and reliable. Combined subcortical and epidural recordings are especially useful in patients with neuromuscular scoliosis or with cerebral palsy that may not have reliable cortical potentials.

[Continual valgum and varum in children treated by stapling (author's transl)]. / Traitement des déviations frontales du genou par épiphysiodèse temporaire de Blount. Etude expérimentale et clinique.

The authors have conducted stapling experiments in 25 rabbits which have shown that, after four weeks, growth was stopped because of lesions of the germinal layer of the growth plate and the formation of bony bridges. They have reviewed the results obtained in 105 children with satisfactory results in 80 p. 100. The cause of some complications have been analysed. The best indication was idiopathic genu valgum of adolescence.

[Perthes' disease treated by Chiari pelvic osteotomy (author's transl)]. / L'ostéotomie de Chiari dans l'ostéochondrite primitive de la hanche. A propos de 17 cas.

The author has studied the results of 17 pelvic osteotomies performed during the course of Perthes' disease in cases in which the femoral head was poorly covered by the acetabular roof. They found improved cover anteriorly and superiorly after operation. Bone remodelling as seen on radiographs and by arthrography was favourably influenced by the better cover. The technical details for the production of a satisfactory osteotomy are given.