Herbert capsuloplasty and Burnei tenomyoplasty for the correction of genu flexum in cerebral palsy, arthrogryposis and posttraumatic.

INTRODUCTION: Studies of gait dynamics revealed the complex motions that the knee must undergo in sync with the hip and ankle, in both the swing and support phase of walking. If these motions are restricted, usually as a consequence of cerebral palsy or arthrogryposis, normal gait is hindered; the patient may be able to walk for very short distances or, eventually, not at all. Children with knee extension limited by 10 - 30 degrees,especially those with cerebral palsy, exhibit a stance compatible with walking. Walking is difficult and the gait pattern, "crouch gait", is considered typical for this degree of limitation. AIM: This paper is meant as an update regarding the usefulness of Herbert knee capsuloplasty, conceived in 1938 and introduced in Romania in 1956 by Clement Baciu, and Burneidistal medial hamstring tenomyoplasty, invented in 1993. MATERIALS AND METHODS: Herbert knee capsuloplasty, although initially intended for ailments other than spasticity or arthrogryposis,became known, in time, as a useful operation for spastic genu flexum with a 15 to 30 degree limitation of extension. Severing the posterior cruciate ligament (PCL) in children less than 10 years old often results in genu recurva tumor joint instability. In order to avoid these complications, PCL transection has been phased out and our clinic started to use, preferentially for spastic genu flexum rather than arthrogryposis,the Burnei tenomyoplasty. When applied in the same operative session, the two techniques complement each other and act in synergy. RESULTS: Herbert capsuloplasty can achieve only partial correction of genu flexum ranging between 30 and 60 degrees of extension deficit. Full extension is opposed by the PCL,contracture of the hamstrings and vascular retraction. Burnei tenomyoplasty used by itself is useful for genu flexum with less than 30 degrees of extension deficit. For children with 30 to 60 degrees of knee extension deficit, combining the Herbertand Burnei procedures achieves the best results. CONCLUSIONS: The simultaneous application of Herbert capsuloplasty and Burnei tenomyoplasty allows for the correction of stiff genu flexum and enables the patient to resume walking,with or without support. This course of treatment also avoids the progression of genu flexum beyond 60 degrees, which would require an osteotomy. This combined procedure avoids the cartilage lesions which may develop when patients with 30- 60 degree genu flexum undergo Herbert capsuloplasty alone.Not in the least, the risk of postoperative knee dislocation is significantly reduced.

Burnei's "double X" internal fixation technique for supracondylar humerus fractures in children: indications, technique, advantages and alternative interventions : Study and Research Group in Pediatric Orthopaedics-2012.

BACKGROUND: The Study and Research Group in Pediatric Orthopedics-2012 initated this retrospective study due to the fact that in Romania and in other countries, the numerous procedures do not ensure the physicians a definite point of view related to the therapeutic criteria in the treatment of supracondylar fractures. That is why the number of complications and their severity brought into notice these existent deficiencies. In order to correct some of these complications, cubitus varus or valgus, Prof. Al. Pesamosca communicated a paper called "Personal procedure in the treatment of posttraumatic cubitus varus" at the County Conference from Bacau, in June 24, 1978. This procedure has next been made popular by Prof. Gh. Burnei and his coworkers by operating patients with cubitus varus or valgus due to supracondylar humeral fractures and by presenting papers related to the subject at the national and international congresses. The latest paper regarding this problem has been presented at the 29th Annual Meeting of the European Pediatric Orthopedic Society in Zagreb, Croatia, April 7-10, 2010, being titled "Distal humeral Z-osteotomy for posttraumatic cubitus varus or valgus", having as authors Gh. Burnei, Ileana Georgescu, Stefan Gavriliu, Costel Vlad and Daniela Dan. As members of this group, based on the performed studies, we wish to make popular this type of osteosynthesis, which ensures a tight fixation, avoids complications and allows a rapid postoperative activity. INTRODUCTION: The acknowledged treatment for these types of fractures is the orthopedic one and it must be accomplished as soon as possible, in the first 6 hours, by reduction and cast immobilization or by closed or open reduction and fixation, using one of the several methods (Judet, Boehler, Kapandji, San Antonio, San Diego, Burnei's double X technique). The exposed treatment is indicated in irreducible supracondylar humeral fractures, in reducible, but unstable type, in polytraumatized patients with supracondylar fractures, in supracondylar fractures with vascular injury, in late presenting fractures, in case of loss of reduction under cast immobilization or in case of surgery with other types of fixation that is deteriorated. We have been using Burnei's osteosynthesis for about 10 years. AIM: This paper aims to present the operative technique, its results and advantages. MATERIALS AND METHODS: 56 cases were treated with Burnei's "double X" osteosynthesis in "Alexandru Pesamosca" Surgery Clinics, from 2001 to 2011. We used the Kocher approach and the aim of surgery was to obtain a fixation that does not require cast immobilization and that allows motion 24 hours after the surgery. The wires placed in "double X" must not occupy the olecranon fossa. The reduction must be anatomical and the olecranon fossa free. Flexion and extension of the elbow must be in normal range after surgery without crackles or limitations. This surgery was performed on patients with: Loss of reduction after 10 days with cast immobilization; Surgery with other types of fixation, deteriorated; Polytraumatized patients with supracondylar fracture; After neglected or late presenting fractures, without the orthopedic reduction made in emergency; Fractures with edema and blistering. RESULTS AND COMPLICATIONS: The patients' ages ranged 3 to12 years old, the mean age for girls was 7,3 years and 6,8 for boys. The hospitalization ranged 3 to 7 days, the average period being of 5 days. The wires had been pulled out after 21 days. The total recovery of the flexion and extension motion of the elbow was, depending on the age, between 21 and 40 days with an average period of 30 days. There were 5 cases of minor complications: in 3 cases the wires migrated outwards up to the 10th day and in 2 cases the wires were found in the olecranon fossa. The CT exam highlighted the impingement effect and the wire that passed through the olecranon fossa had to be removed between the 7th and the 9th day. No reported cases of cubitus varus or valgus were reported. CONCLUSION: The Burnei's "double X" osteosynthesis does not require cast immobilization. In oblique fractures, the stability is more difficult to obtain and by using other methods, elbow stiffness or ulnar nerve palsy may appear. The Burnei's "double X" osteosynthesis ensures stability of these types of fractures and avoids complications. This technique allows early motion after surgery and, in case of polytrauma, ensures comfort both to the patient and the physician, allowing repetitive examinations, preferential positions or the nursing of the extensive skin lesions.