Chronic recurrent multifocal osteomyelitis causing spinal cord compression.

Chronic recurrent multifocal osteomyelitis (CRMO) is a very rare condition of unknown etiology and most commonly occurs during childhood or adolescence. The purpose of this paper is to present a case of CRMO in a vertebral location with severe kyphosis, spinal cord compression, and neurological dysfunction requiring anterior decompression and fusion. After 12 weeks, the patient was physically able to return to school. At 2-year follow-up, neurological and functional outcomes are fair. Magnetic resonance imaging shows good restoration of the sagittal spine alignment despite residual mild kyphosis, and restoration of a normal sagittal diameter of the spinal canal.

Ipsilateral omovertebral bones in the levator scapulae muscle and the rhomboid muscle in a Sprengel deformity: case report.

Our interest was stimulated by the uncommon case of a 4-year-old girl who presented a Sprengel deformity associated with two omovertebral bones on the same side. The first omovertebral bone was situated in the levator scapulae muscle and the second omovertebral bone was lying in the rhomboid muscle. The removal of these two bones was combined with a Woodward procedure to obtain a good correction.

[Anterior spinal fusion by thoracoscopy. A non-traumatic technique]. / La spondylodèse antérieure sous thoracoscopie: une technique atraumatique.

PURPOSE OF THE STUDY: Video assisted thoracic surgery (VATS) is a new modality which allows visualization of, and access to the intrathoracic organs without thoracotomy. Recently, this technique has been used for anterior thoracic spine approach to perform surgery which previously required standard postero-lateral thoracotomy. The authors report their initial experience of anterior spinal fusion using thoracoscopy and give a detailed description of their surgical procedure. MATERIAL AND METHODS: This technique, started on June 1993, was performed only in one level 1 in 10 patients who had thoracic spine trauma with fracture or luxation. The procedure was performed in the lateral decubitus position. The patient was prepared in the standard manner for a full thoracotomy. Surgical instruments that are needed for conversion to an open procedure must be in the operative room. Ventilation was stopped to the ipsilateral lung. Lung's collapse of the surgical side was obtained with a double lumen tube. Carbon dioxide (CO2) insufflation was used to further collapse. The first thoracoscopic portal was placed through the sixth or seventh intercostal space in the posterior axillary line, which was the safest place. All subsequent portals were placed under thoracoscopic visualization, in a triangular way as recommended by Landreneau (1992). Only open trocars were used to avoid complication of CO2 insufflation. Once the target level has been defined, a needle was placed into the disc space and roentgenographic confirmation obtained. The parietal pleura was then divided using monopolar electrocautery. Segmental vessels of the operation field lied transversely across the midportion of the vertebral body. They were mobilised and systematically ligated with endoscopic clip to simplify the procedure. Then the intervertebral space was opened and bone and disc were removed, restricted to the anterior and middle third. The graft was placed into the thoracic cavity by using a high density calcium hydroxyapatite ceramic block. Peroperative radiologic control ascertained the good position of the implant. At the end of the procedure a chest tube was placed through the lower trocar site and the lung re-expanded. A post operative CT Scan controlled good position of the graft and complete lung expansion. Contra-indications for VATS are previous surgical procedures or empyema causing extensive pleural adhesions. Procedures not appropriate for VATS approach are some that require anterior instrumentation for stabilisation, burst fracture, or fracture with posterior wall involved. RESULTS: The planned procedure was accomplished in all but one patient who required conversion to an open procedure because of segmental artery bleeding. Mean operative time was 1 h 45 mm, and mean estimated blood loss was 650 cc. There was no complication from CO2 insufflation neither postoperative complication. With an average of 2 years follow up, anterior grafting is as good as an open technique, radiologic evaluation according to Uchida (1990) showed good incorporation of each block without any radiolucent line or displacement. DISCUSSION: According to literature this technique was performed safely in 10 cases, especially without any respiratory complications and chronic pain (impairement of pulmonary function, re-expansion failure, incisional complications, rib fractures, chronic pain and malfunction of the chest wall, limitation of shoulder girdle motion) which are considered to be the main disadvantage of traditional thoracotomy. Many authors previously used VATS for multi level thoracic discectomy for correction of spinal deformities (Mack 1995), spinal reconstructive surgery (Mac Afee 1995) or removal of protrude thoracic disc (Rosenthal 1994). CONCLUSION: This original technique demonstrates that thoracoscopy for anterior thoracic surgery is better for the patients, reducing surgical trauma of the chest wall and to the lung parenchyma (in term of post operative comfort, sh

[Scaphoid and lunate palmar divergent dislocation. Apropos of a case]. / La luxation palmaire et divergente scapho-lunaire. A propos d'un cas.

UNLABELLED: A case of palmar dislocation of the scaphoid and lunate which where dissociated from each other is reported with a 3.5 years follow up. A 32 years old man fell while reading his motorcycle. He landed on his left hand dorsiflexed. There was no skin dilaceration and neuro-vascular status of his hand was intact. X-rays showed a palmar dislocation of the scaphoid and lunate with a large gap between the two bones. The lunate was also completely dissociated from the triquetrum and the capitate. Distal pole of the scaphoid remained in contact with the trapezium. The patient was taken to the operating room, and after unsuccessful closed reduction, an open reduction through a palmar approach was performed. A complete disruption of the anterior capsule was founded and all perilunate ligaments were completely disrupted. Reduction was easy under direct vision, and the anterior capsule was repaired. A non displaced trapezium fracture seen at surgery was fixed with a Kirschner wire. A long arm cast applied for 6 weeks. At 3.5 years follow-up, the patient had an almost full range of motion and no residual pain. Power grip was 25 per cent reduced in comparison with the opposite side. X-rays showed a palmarflexed scaphoid and Magnetic Resonance imaging showed no evidence of avascular necrosis. DISCUSSION: Simultaneous dislocation of scaphoid and lunate as a unit or with a large gap between the two bones are extremely rare injuries. In all cases already reported, results were briefly presented without any available clinical and radiological data because patients were lost for follow-up. In our case report, the anatomy and kinematics of the wrist showed the lack of our initial treatment with a single volar approach, anterior capsular reparation and a long arm cast alone. In fact, at 3.5 years follow up, ligamentous healing was inadequate to control compressive forces across the wrist and the scaphoid volarflexed despite a good alignement in the cast. Although the functional results is good, radiological outcome is far from being good. This case demonstrated that even in early treatment with a good position of carpal bones in the sole cast, healing of the ligamentous system without loosing reduction is difficult. CONCLUSION: In such a case, and with a low rate of avascular necrosis in perilunate dislocations treated early we suggest an open reduction and internal fixation (O.R.I.F.) to prevent carpal instability. We recommend combined volar and dorsal approaches for repairing anterior and posterior ligaments (especially interosseous ligaments on both sides of the lunate), associated with a stabilization of the entire carpum by scapho-lunate, triquetro-lunate, and capito-lunate Kirschner wire fixation.

Brachialis arteria rupture following closed posterior elbow dislocation. Case report and literature review.

Although isolated posterior closed elbow dislocation occurs frequently, associated disrupted brachialis arteria is an uncommon complication which is rarely encountered. The rarity of this complication makes adequate management of this injury controversial, but arterial reconstruction remains the treatment of choice and is recommended despite reports of success following simple arterial ligation. Complications such as intermittent claudication or gangrene of the hand are possible if brachial artery flow is not restored.

[Surgical approach to the axillary nerve via an anterior trans-coracoid route]. / Abord chirurgical du nerf circonflexe par voie antérieure transcoracoïdienne.

The surgical approach to the circumflex nerve is difficult. Based on an illustrative clinical example, the authors describe a method using a coracoid osteotomy that permits a simplified approach to the circumflex nerve. This trick permits en bloc retraction of the superficial plane of the brachial plexus without sectioning of the muscle and without excessive traction on the musculocutaneous nerve. The stable fixation of the coracoid at the end of the procedure permits early and effective rehabilitation.

[Classification of femoral shaft fractures in hip arthroplasties]. / Classifications anatomo-radiologiques des fractures du fémur sur implant fémoral - Revue de la littérature.

Fractures of the femoral shaft around cemented hip prosthesis have become increasingly common and are difficult to manage. These fractures are often complex and may occur late after the insertion of a cemented prosthesis. They often occur in relation to cortical defects produced by cement and previous surgery. The main classifications already described can be divided into "anatomic" classifications (founded on the level of the fracture on the shaft: Parrish 1964, Ali Khan 1977, Van Elegem 1979) or into "prosthetic" classifications (founded on the level of the fracture with respect to the tip of the prosthesis: Johansson 1981, Bethea 1982, Cooke 1988). But these classifications give few guideliness to help the choice of the most appropriate form of treatment. The aim of treatment, which remains controversial, is to return to weight-bearing and mobility as promptly as possible so preventing the complications of immobilization which are frequent and serious in the often elderly population.

[A nail for progressive lengthening. An animal experiment with a 2-year follow-up]. / Clou d'allongement progressif. Expérimentation animale avec un recul de deux ans.

The elongation nail was experimented on 10 pure-breed Romanov ewes aged 9 to 12 month-old. It was implanted in a randomly chosen femur, the other femur being used as a control. After a superior and lateral approach to the femur, drilling and initial distraction averaging 26 mm, the nail was inserted and locked at both ends. Lengthening began at D1 by alternate inward and outward rotation maneuvers exerted on the pelvic limb. One ewe presented an intraoperative hip dislocation, another one unlocked the upper lock, with secondary shortening. The other 8 ewes underwent successful lengthening without apparently suffering (63-mm gain, i.e. 37% at the end of lengthening). Two ewes died at 9 months and their femura presented with a space remaining to fill smaller than 3 mm. Five of the other 6 ewes were followed up for an average of 10 months after bone healing and nail removal, over a total follow-up of 2 years. The femur is modified all over its diaphysis and widened at the level of the regenerated tissue, where cortical bone is thinner but has a normal lamellar appearance. Bone marrow is replaced by trabecular bone filled with fatty marrow. The pathology study of the last of the 6 ewes followed up for 2 years showed a bridge between both sites of incipient regeneration, indicating bone healing. The final gain as compared to the non-operated side is 27%. Progressive lengthening can be performed with an internal fixator in animals. The clinical trial in progress with allow evaluating this technique and establishing its field of application.

Lower limb-length discrepancy. An epidemiologic study.

Two retrospective epidemiologic studies have examined the incidence and prevalence of significant lower limb-length discrepancy and the number of surgical corrections by lengthening in 1987 in France. The incidence of apparatus prescriptions for asymmetry correction filled was 2.16 per 100,000 population. The prevalence of people using a corrective apparatus was one per 1000 population. The male-to-female ratio was 1.95:1. Because of biases in the study population, the actual incidence and prevalence of significant limb-length discrepancies is likely to be considerably higher. A questionnaire administered to surgeons of the French Orthopedic Society revealed that the majority of surgical lengthenings were performed by large orthopedic teams. In the 418 procedures reported, the tibia was lengthened more often than the femur (ratio 1.1:1). Gradual distraction techniques were used in 89.4% of cases, with the Ilizarov apparatus used in 57.4%, the Wagner apparatus in 20.6%, and the Orthofix fixator in 11.2%. Immediate distraction techniques were used in 7.9% of cases, 85% of which were done on the femur. Average total lengthening was 51 mm for tibia and femur. Average lengthening was greater for methods of gradual distraction (53.5 mm) than for immediate distraction (31.4 mm).

Anatomic basis of a superior approach to the acetabulum with osteotomy of the ala of the ilium.

This study demonstrates the importance of a superior approach to acetabulum with intrapelvic osteotomy of the iliac ala in certain fractures of the acetabulum. This study is based on the dissection of 15 formolized and 5 frozen subjects, the surgical treatment of 17 acetabular fractures, and the performances of 2 Chiari-type osteotomies and 2 Salter-type osteotomies. We investigated the gluteus medius muscle and its pedicle in relation to the iliac ala. Landmarks for the osteotomy lines and the gluteal pedicles are defined in terms of the requirements of different surgical approaches. The superior approach for acetabular fractures was made using a skin incision of Smith-Petersen type. The underlying principle is the performance of an intrapelvic osteotomy of the iliac ala, the anterosuperior part of the ala being tilted outward and backward and pedicled on the gluteal muscles. This provides intra- and extrapelvic exposure of the acetabular walls. The advantages and drawbacks of this route of approach in surgery of the pelvic girdle are discussed in terms of the types of fracture treated and tumoral locations. The anatomic findings are illustrated from traumatology and tumoralpathology. This approach seems particularly suitable for acetabular fractures interrupting the pelvic ring.

[Treatment of subluxation and dislocation of the patella in the child. Elmslie technic with movable soft tissue pedicle (8 year review)]. / Die Behandlung der Subluxation und Luxation der Kniescheibe beim Kind. Technik von Elmslie mit beweglichem Weichteilstiel (8-Jahres-Ubersicht).

The Elmslie method using a soft-tissue strip aims at realigning the extensor mechanism in the same way as the Elmslie-Trillat operation in adults. We feel that the main cause of dislocation or subluxation of the patella is to be found in incorrect alignment of this mechanism. We feel that the Q angle should especially be correct with regard to knee stability during rotation. This angle should not be neutralized or even inverted. In young, growing patients, as compared to adults, excess stress on the medial side due to medial displacement of the tuberosity will be compensated for by increasing valgus of the knee joint. Analysis of the potential risks involved in this pretuberosity operation led us to the conclusion that there is no risk of early epiphysiodesis or bony recurvation, and no risk of patella baja or osteochondrosis of the tuberosity. The functional results are so far very satisfactory (13 of 17 reexamined cases continue to be involved in sports or have taken up sports); this is particularly rewarding if we consider that the operation is not technically demanding and may even be undergone by ambulatory patients.