[Legg-Calve-Perthes disease]. / La maladie de Legg-Perthes-Calvé: challenge étiologique, thérapeutique et pronostique.

Treatment of Legg-Calvé-Perthes disease remains, in spite of realized progresses, difficult and disturbing. The important factors for establishing diagnosis concerning definition, etiology, physiopathology and clinical manifestations are reminded. The role of present complementary investigations as well as their evolution are very important to better establish the prognosis and the treatment. The most important factors for treating and establishing the prognosis of LPC are: 1) age. The prognosis is good in almost every case before 5 years old, without any treatment; 2) the prognosis is not good after 9 years, also, very often, after surgical treatment; 3) area of the epiphyseal necrosis, particularly of the lateral pillar; 4) extrusion of the hip at any age. Today, there is always no causal treatment of Legg-Calvé-Perthes disease. Conservative and surgical treatment aims to prevent deformities of the femoral head accompanied or not by articular incongruency, responsible for hip arthritis from the fourth decade. The place of conservative and surgical treatment as well as their complications are described; it aims to guide the spontaneous recovery with as little as possible, deformation of the femoral epiphysis.

[Gait disorders and lower leg deformities in children]. / Mon enfant marche mat les anomalies du morphotype des membres inférieurs.

Gait disorders and lower legs deformities in children are frequent causes of parental concern and of medical advice. These deformities should be analysed systematically as well as their consequences for daily activities. We should define precisely type, localisation and importance of the deformity: femoral or tibial torsion, knock knees, bow legs. The evaluation should always be done according to age of the child because these deformities are most often a step toward adult morphotype. Sometimes they could be the manifestation of some generalised or localised pathology that should be investigated and treated. Nevertheless patience and explanations, regular follow-up allow to reassure the parents. There is in the great majority of case no place for any conservatrice and especially surgical treatment for theses disorders spontaneously healing in 95% of cases.

Mechanical characterization of brushite and hydroxyapatite cements.

Compression, tension and torsion tests were designed and completed successfully on a brushite and a precipitated hydroxyapatite cement in moist condition. Elastic and strength properties were measured for these three loading cases. For each cement, the full set of strength data was fitted to an isotropic Tsai-Wu criterion and the associated coefficients identified. Since the compressive Young's moduli were about 10% larger than the tensile moduli, the full set of elastic data of each cement was fitted to a conewise linear elastic model. Hysteresis of the stress-strain curves was also observed, indicating dissipation mechanisms within these cement microstructures. A comparison of the measured mechanical properties with human cancellous bone confirmed the indication of brushite as a bone filling material and the potential of the hydroxyapatite cement as a structural biomaterial.

Pathologic fracture of the femur neck as first manifestation of a minute columnar cell carcinoma of the thyroid gland.

This case report concerns a 64 year-old woman who presented a pathologic fracture of the femur neck. Histologic examination of the performed bone biopsy disclosed the presence of a carcinomatous metastasis with unusual microscopic features. The site of the primary tumor could be unequivocally determined as being the thyroid gland, as immunostaining of the tumor cells showed positivity with anti-thyroglobulin. The thyroidectomy specimen weighed 149 g, was nodular and partially calcified. Exhaustive microscopic examination finally revealed the presence of a minute columnar cell carcinoma, 0.6 cm in diameter, with obvious vascular invasion. This case illustrates well 1) the usefulness of immunostaining with anti-thyroglobulin in cases of bone metastasis with unusual microscopic features and unknown primary, as well as 2) the aggressiveness of this rare type of carcinoma of the thyroid.

Avascular necrosis after osteotomy of the talar neck to correct residual club-foot deformity in children. A long-term review.

In order to determine the incidence of avascular necrosis after osteotomy of the talar neck, we re-evaluated 11 patients (16 feet) with idiopathic club foot who had undergone this procedure at a mean age of eight years (5 to 13) to correct a residual adduction deformity. All had been initially treated conservatively and operatively. The mean follow-up was 39 years (36 to 41). Surgery consisted of a closing-wedge osteotomy of the talar neck combined, in 14 feet, with lengthening of the first cuneiform and a Steindler procedure. At follow-up eight feet were free from pain, three had occasional mild pain and five were regularly painful after routine activities. Two patients were unlimited in their activity, six occasionally limited after strenuous and three regularly limited after strenuous activity. Using the Ponseti score, the feet were rated as good in four, fair in three and poor in nine. In seven feet avascular necrosis with collapse and flattening of the talar dome had occurred. In all of these feet the children were younger than ten years of age at the time of surgery. In three feet, avascular necrosis of the talar head was also observed. We conclude that osteotomy of the talar neck in children under the age of ten years can cause avascular necrosis and should be abandoned.

Hypoplasia of thoracic pedicle: CT diagnosis. A case report with emphasis on CT diagnosis.

A rare case of hypoplasia of a left pedicle of T11 is reported. The contribution of computed tomography to assess the diagnosis and display the eventual associated malformations of the neural arch is discussed.

The scarf osteotomy for the treatment of hallux valgus deformity: a review of 84 cases.

This study reviewed the subjective, clinical and radiological outcome of 71 patients (84 feet) treated by scarf osteotomy for hallux valgus deformity at our institution from 1995 to 1998 with an average follow-up time of 22 months (range, 17 to 48 months). At the time of follow-up, 39% of the patients were very satisfied, 50% were satisfied and 11% were not satisfied. The mean AOFAS score raised significantly from 43 points (14-68) preoperatively to 82 points (39 to 100) at follow-up (p < 0.001). The radiological angles including M1-M2, M1-P1, M1-M5 and DMAA improved significantly (p < 0.001). Among the 16 complications recorded, seven (8%) were minor and nine (11%) required an additional procedure. The scarf osteotomy of the first metatarsal coupled with a lateral soft-tissue release and, in three-quarters of our cases, with a basal closing wedge varisation osteotomy of the first phalanx, resulted in overall high satisfaction rate as well as significant clinical and radiological improvements in our series. Nevertheless, the range of motion of the first MP joint remained low: 30 degrees to 74 degrees in 52 patients (62%) and <30 degrees in four patients (5%). Furthermore, the mobility of the first ray as well as the consequences of the procedure in the sagittal plane need to be assessed more accurately, and this may be achieved by incorporating measurement of the plantar pressures in the forefoot area into the global rating system.

Simplified 3D-evaluation of periacetabular osteotomy.

Reorientation osteotomies are widely used for the treatment of residual dysplasia of the hip. Preoperative planning is mandatory, and 3D-evaluation is of utmost importance for precise definition of direction and magnitude of displacement of the acetabulum. Instead of a 3D-CT scan reconstruction which needs multiple slices, we developed a 3D-reconstruction from a single AP pelvic view. This method is applicable if we accept that the femoral head and acetabulum are quite spherical. Appropriate software and a PC are used for this reconstruction that we compared with 3D CT-scan reconstruction and pelvic anatomical preparations. Twenty-two patients, 17 female, 5 male, with hip dysplasia, were treated by periacetabular osteotomy according to Ganz. The mean age was 27 years (14-40 years); the mean follow-up, 4.8 years (2-7 years). Four patients were treated conservatively in infancy for DDH, one patient had snapping hips associated with hip dysplasia, and two patients had slight sequellae of cerebral palsy. All patients were symptomatic mainly during daily activities or sports. The clinical evaluation was done using the Charnley scoring system. The Charnley score for pain improved from 3.6 (2-3.5) to 5.8 (5-6) at follow-up. No restriction of mobility or of walking capacity was observed after operation. The computer-assisted method also permits appreciation of the evolution of classical coxometry; i.e. Wiberg and Lequesne angles. The improvement after Ganz osteotomy was respectively 141% and 161% for Wiberg and Lequesne angles without any posterior uncoverage. The 3D-evaluation showed an improvement of 28% of the vertical projection area of the acetabulum on the femoral head. The anterolateral coverage improved from 20.3 to 50.1%. The Ganz osteotomy is really a 3D-reorientation osteotomy. With our simplified method it is possible to predict and control the amount of displacement to be done. However, we have to keep in mind that the articular cartilage is a limited crescent in the acetabulum; this method cannot replicate exactly the form and shape of articular cartilage. At this time it allows us to better control the amount of displacement during operation to avoid too large a displacement or lateralization.

[Long-term development of tibio-astragalus arthrodesis]. / Evolution à long terme des arthrodèses tibio-astragaliennes.

Twenty-eight arthrodeses of the ankle have been reviewed with a mean follow-up of nine-and-a-half years. The arthrodeses were all carried out using the same technique of osteotomy of the lateral malleolus and fixation with a Charnley compression device. The main indication for fusion was post-traumatic arthritis. The number of complications, most of them benign, was not negligible and amounted to 42 per cent, including superficial infections, skin necroses and lesions of the posterior tibial nerve. Revision operations were needed in 17.5 per cent of cases during the year after operation, most of them for malposition. The clinical results were satisfactory in three-quarters of the cases and poor in one-quarter. Radiological changes in the joints distal to the fusion were relatively marked in the subtaloid joint and slightly less in the midtarsal joint. Theses changes are a source of concern for the future because of their pre-arthritic appearance and their progressive nature. Adaptive hypermobility of the midtarsal joint was seen in only one-third of the cases. The changes were greater when the hindfoot was in equinus, a position which was often aimed for in this series. The author advises internal fixation with screws and discusses the future potential for arthroplasty.

[Percutaneous epiphysiodesis in the treatment of adolescent genu valgum]. / Epiphysiodèse percutanée dans le traitement du genu valgum de l'adolescent.

UNLABELLED: Persistent genu valgum in adolescent induce abnormal gait and functional disturbances. Surgical correction should prevent secondary osteoarthritis. MATERIAL AND METHODS: Twenty three percutaneous epiphysiodesis in 12 children are reviewed at the end of growth. The surgical technique and the X-ray evaluation and timing calculation of epiphysiodesis according to Bowen are described. RESULTS: The supine intermalleolar distance is reduced from 11.8 cm to 2.8 cm. The femoro-tibial angle is reduced from 12.9 degrees to 7.9 degrees and distance between mechanical axis and center of knee from 25.3 mm to 8.6 mm. These results are very good, without any complications. DISCUSSION: Percutaneous epiphysiodesis is really a mini-invasive and cost effective method for treatment of genu valgum. The results are at least as good as in Blount stapling without any complication or second surgery for hardware removal. The timing of epiphysiodesis remain a difficult problem and the physician should be very cautious in determining the good time for surgery. CONCLUSION: Percutaneous epiphysiodesis is today the treatment of choice for genu valgum. This method is non invasive and cost effective.

[Hallux valgus: the McBride procedure or subcapital osteotomy?]. / Hallux valgus: intervention de McBride ou ostéotomie sous-capitale?

The authors compared the long term follow-up (mean duration 19 years) of 96 patients operated on for hallux valgus, 52 by the McBride procedure, 46 by a Hohmann procedure. Clinical results considered 4 criteria: deformity, pain, mobility and satisfaction. Dorsoplantar weight bearing X-ray compared anatomical results. This study showed that patients were subjectively more satisfied after McBride operation (p = 0.0001) even if the deformity was radiologically better reduced by osteotomy (p = 0.006). This discrepancy between subjective and radiologic results was related to the fact that X-rays represent only the static morphologic reflect of a more complex pathologic entity: radiology can only partly explain the functional discomfort of the patients. The modified McBride procedure was better suited to patients presenting a painful HV. Osteotomy was more suited to bunions causing little pain. Indications for each of these procedures should be based more on patient's history and clinical examination than on X-rays.

[Primary synostosis of the tarsus in children. Apropos of 32 cases in 20 patients]. / Les synostoses essentielles du tarse chez l'enfant. A propos de 32 cas chez 20 patients.

The authors have studied 32 tarsal coalitions in 20 children. Twenty two were between the talus and the calcaneum, 4 were medial and 6 were rare varieties. The diagnosis is often missed because 40 p. 100 of the children with tarsal coalition had no complaints. The indirect radiological signs have been analysed and precise techniques described for detecting the coalition. Only 11 feet were operated on. On 4 occasions the coalition was simply resected. This always gave a good functional result and good mobility was obtained in the subtaloid joint in 2 cases. The other cases were treated by triple arthrodesis. The authors consider that an earlier diagnosis would lead to better prevention of secondary deformities. The best indication for simple resection is in coalition between the calcaneum and the navicular.

[The fate of children undergoing bone lengthening in congenital hypoplasia of the legs]. / Le devenir des enfants opérés d'allongement pour hypoplasie congénitale des membres inférieurs.

This retrospective study was conducted on 26 patients, 14 women and 12 men whose average inequality prognosis was 8.5 cm. They have been reviewed after they were more than 20 years old (mean 23.8 y). Between 1962 and 1979 these 26 patients have had 38 lengthening procedures with various methods. The results were evaluated after clinical examination and X-rays. The average radiological discrepancy was 1.5 cm at the follow-up. On the X-rays, the deterioration was rare for the hip point, more frequent for the knee and very frequent for the ankle and the foot. If the socio-professional integration was satisfactory, many problems remained unsolved at the review. The matter was the aspect of the lengthened limb considered as unesthetic and ugly by 22 patients. 20 of the 26 patients had problems to put on shoes. On the other hand two patients out of three had a relative intolerance to effort, cutaneous troubles probably in conjunction with vascular and trophic insufficiency with many concern for the future.

[Surgical treatment of scoliosis of 100 degrees and greater in children and adolescents (neurological and myopathic scoliosis excluded). Apropos of a series of 66 cases]. / Traitement chirurgical des scolioses de 100 degr'es et plus chez l'enfant et l'adolescent (à l'exclusion des scolioses neurologiques et myopathiques). A propos d'une série de 66 cas.

In a retrospective study the authors had compared the results obtained in two series of identical scoliosis. All were examined after a two year minimal follow-up. Group A. There were 31 children operated on between 1966 and 1972. The average initial curve measured 111 degrees, and the average follow-up was eight years. In this group there was no preoperative preparation, and a Harrington rod was accompanied by cancellous grafting. The average correction was 34 degrees. Four paraplegias were seen, three of which recovered. Group B. There were 45 children operated on between 1973 and 1980. The average initial curve was 170 degrees and the average follow-up was 4.5 years. In this group, there was pre-operative use of a Halo cast routinely. In 14 children, Harrington rodding was supplemented by anterior fusion to correct associated kyphosis. The posterior Harrington rodding was completed by tibial grafting. The average correction was 47 degrees, without any neurological complications. It was noted that after one year, pulmonary function was not impaired to a greater extent after an anterior fusion than after a purely posterior fusion. Two-thirds of the cases gained considerable cosmetic benefit.

[Cryopreservation and bone transplantation]. / Cryoconservation et transplantations osseuses.

Massive bone allografts allow us to treat easily large osseous defects. This study reports our experience with 90 massive allografts of whom 50 had more than 2 years follow-up. The reconstruction was in half of cases the femur, in ten patients one or more vertebra, hemipelvis in five, humerus in four and tibia in three cases. The main indication was tumor surgery: 30 malignant, 6 benigns, but also for the treatment of massive bone loss in ten prothesis replacement and in 4 miscellaneous pathology (malformation, infection ...). The massive allografts allow us more anatomic reconstructions and particularly in young patients we can observe some rehabitation of the graft by host cells. The complication rate is quite high mainly mechanical (10 fractures) in the first two years following surgery, but also 2 sepsis and 2 sciatic palsy. Simultaneously an experimental and morphological study of cartilaginous fragments was undertaken: at first, we define the best method of fixation and examination of human articular cartilaginous fragments by electronic microscopy. This method was then applied to cartilaginous fragments liable to various cryoprotective solutions, stocked for various periods at different temperature and subjects to programmed cryocongelation. So we are able to define the best conditions of cryoconservation of human adult articular cartilage fragments and we can observe that 70-80% of cells maintain normal morphological structure suggesting a perfect cellular viability.

[Valgus deformities of the ankle in children]. / Les déviations en valgus de la cheville chez l'enfant.

In children valgus deformities of the ankle joint are usually due to neurological conditions (spina bifida, poliomyelitis, spasticity). The deformity is characterized by a shortened fibula, wedging of distal tibial epiphysis and valgus tilt of the talus. Other conditions producing similar deformity include congenital and acquired fibular pseudarthroses, multiple exostoses and some cases of tarsal synostosis. Early treatment of a progressive valgus in multiple exostoses is mandatory. The author describes a case of ankle valgus following an undiagnosed traumatic section of tibialis posterior tendon. After predictable failure of a Grice procedure, a persisting good correction was obtained by fibula lengthening combined with talus reposition and fixation on os calcis.