Pediatric osteoarticular infections caused by Streptococcus pneumoniae before and after the introduction of the heptavalent pneumococcal conjugate vaccine.

Streptococcus pneumoniae is an uncommon cause of osteoarticular infections (OAI) in children. The objective of this study was to investigate the clinical and laboratory characteristics of pneumococcal OAI before and after the introduction of the heptavalent pneumococcal conjugate vaccine (PCV7). Data were retrospectively collected from children aged <16 years who were hospitalized for pneumococcal OAI between 1997 and 2007 in four Parisian teaching hospitals. Forty-three children were included (32 with arthritis and 11 with osteomyelitis) and the median age of these children was 12.5 months (range 3 months to 14 years). Serotypes were available for 19/43 strains (44 %) from 1997 onwards and for 12/13 strains (92 %) from 2005 onwards. Seven unvaccinated children were infected with vaccine serotypes and we observed only one vaccine failure. After the introduction of PCV7, we noted an increase in short-term complications and the emergence of serotype 19A, which was penicillin-intermediate in 86 % of cases. After PCV7 introduction, serotype 19A was the most frequent serotype implicated in pediatric pneumococcal OAI. The 13-valent pneumococcal conjugate vaccine introduced in France in June 2010 should cover the emerging serotype.

Delayed-iatrogenic injury of the thoracic aorta by an anterior spinal instrumentation.

We present a case of a 15-year-old girl who presented to us with an unusual low back pain. About 7 years ago, this patient had corrective surgery for her idiopathic left thoracolumbar scoliosis. Recent surgery revealed a laceration of the posterior wall of the thoracic aorta by an impending screw thread. This injury was repaired by the vascular surgeons and, subsequently, the patient had full recovery without any complications.

Understanding the foot's functional anatomy in physiological and pathological conditions: the calcaneopedal unit concept.

BACKGROUND: A thorough review of the available orthopaedic literature shows significant controversies, inconsistencies and sparse data regarding the terminology used to describe foot deformities. This lack of consensus on terminology creates confusion in professional discussions of foot anatomy, pathoanatomy and treatment of deformities. The controversies apply to joint movements as well as static relationships between the bones. DESCRIPTION: The calcaneopedal unit (CPU) is a specific anatomical and physiological entity, represented by the entire foot excepted the talus. The calcaneus, midfoot and forefoot are solidly bound by three strong ligaments that create a unit that articulates with the talus. The movement of the CPU is complex, as it rotates under the talus, around the axis of Henke that coincides with the talo-calcaneal ligament of Farabeuf.This calcaneopedal unit is deformable. It is compared with a twisted plate, able to adapt to many physiological situations in standing position, in order to acheive a plantigrade position.Moreover, the calcaneopedal unit and the talo-tibiofibular complex are interdependent; rotation of the latter produces morphologic modifications inside the former and vice versa. PURPOSE: This paper is a review article of this concept and of its physiopathological applications.

[Protective limp]. / Boiterie.

Limping in a child is a frequent reason for consultation, sometimes as an emergency. A distinction should be made between a protective limp, to avoid painful weight bearing, and an equilibration limp, which corresponds to an adaptation to a disturbance of muscular activity with a neuromuscular or osteoarticular origin. Etiological analysis of a protective limp is essentially based on the history and examination. Further radiological or biochemical investigations contribute to the diagnostic process and are essential in limps of recent onset. Broadly speaking, in children aged between one and two years, the main etiological hypothesis, in terms of frequency and potential seriousness, is osteoarticular infection, although fractures are also common. In children aged between three and eight years, osteoarticular infection should be sought as a priority. The diagnosis of acute transient synovitis (irritable hip) should only be made after excluding other conditions including benign bone tumours (such as ostioid osteoma), malignant tumours, inflammatory monoarthritis, primary osteochondritis of the hip, trauma with or without fracture, apophysitis, leukemia, etc. The diagnosis of acute transient synovitis should be questioned if the condition persists for more than seven days. After the age of nine years, the diagnosis that is important not to miss is proximal femoral epiphysiolysis, because this condition can have serious implications for the future function of the hip. The other diagnoses already cited remain possibilities. Finally, a psychogenic aetiology, tendinitis, or sprain should not be considered in children, and they risk delaying the diagnosis of a potentially serious condition. The aetiology of an equilibration limp is based on a precise clinical examination, aimed at detecting orthopedic or neurological pathology, which will direct further investigations.

[Surgical treatment of stiff massive knee endoprosthesis for bone tumors in children and adolescents]. / Traitement chirurgical de la raideur après prothèse massive du genou pour tumeur osseuse chez l'enfant et l'adolescent.

PURPOSE OF THE STUDY: Improved oncologic outcome and technical advances in limb salvage surgery have made limb salvage therapy a feasible and valuable treatment option. Nevertheless, resection of a bone tumor followed by a reconstruction knee endoprosthesis can create gait abnormalities, of which one of the most frequent is knee stiffness. The aim of this retrospective study was to assess the outcomes of revision surgery for a stiff knee following reconstruction of a segmental long bone defect. PATIENTS AND METHODS: Between 1983 and 2005, 19 patients who had undergone wide resection of a tumor close to the knee followed by reconstruction with a massive endoprosthesis were revised for a diagnosis of stiffness. RESULTS: The mean age of the patients was 12 years (range: 7-19 years). Patients were followed for a mean five years (range: 1-21 years). Three patients were not assessed at the last follow up (two patients died, one patient was amputated for a local recurrence). The mean range of motion improved 80+/-24 degrees preoperatively to postoperatively. The Enneking score improved from 15+/-0.5 to 23+/-3 points at three months follow-up, and to 22+/-5 at last follow-up. Recurrent stiffness occurred three times and required a second operative release with a good final result. DISCUSSION: Outcome depends on the cause of the stiffness of the reconstruction knee arthroplasty. Stiffness can be caused by complications (trauma, implant failure, infection), and patient-related factors (lack of physiotherapy). Open arthrolysis is indicated for chronic stiffness in a motivated patient with an identified cause because failure to identify the cause of stiffness may result in recurrence of the problem.

[Childhood cerebral tumors: morbidity and follow-up into adulthood]. / Tumeurs cérébrales de l'enfant: morbidité et suivi à l'âge adulte.

This chapter presents guidelines for the follow-up of children with brain tumors, whether benign or malignant, in their transition to adulthood. The consequences of their disease and its treatment overlap greatly. The complications and long-term follow-up are detailed based on the specialists involved.

Closed reduction in late-detected developmental dysplasia of the hip: indications, results and complications.

PURPOSE: The aim of the study was a review of the literature in order to evaluate the results and complications of closed reduction in late-detected developmental dysplasia of the hip (DDH). METHODS: This study consisted of an analysis of the literature relative to late-detected DDH treatment options considering hip congruency, rates of re-dislocation and of avascular necrosis. RESULTS: Gradual closed reduction (Petit-Morel method) appears to be an effective method concerning joint congruency restitution. Dislocation relapse and avascular necrosis are more efficiently prevented with closed versus open reduction. The tendency for spontaneous correction of acetabular dysplasia decreases if closed reduction is performed after 18 months of age. Patient age at the beginning of traction should be considered for the prognosis, with a lower rate of satisfactory results showing after the age of 3 years. CONCLUSION: In our opinion, the Petit-Morel method is a suitable treatment option for children aged between six months and three years with idiopathic DDH.

Anterior and lateral overcoverage after triple pelvic osteotomy in childhood for developmental dislocation of the hip with acetabular dysplasia: Frequency, features, and medium-term clinical impact.

BACKGROUND: Triple pelvic osteotomy (TPO) is a treatment option in children and adolescents with residual acetabular dysplasia after developmental dislocation of the hip (DDH). However, TPO to redirect the acetabulum is often blamed for anterior and lateral overcoverage of the femoral head. The main objectives of this study were to assess the potential clinical impact, frequency, and radiological features of acetabular overcorrection. Evidence of post-operative remodelling and associations linking younger age at surgery and/or dysplasia severity to the existence and magnitude of overcorrection were sought. HYPOTHESIS: Acetabular overcorrection has little or no clinical impact. PATIENTS AND METHODS: TPO was performed on 41 hips in 31 patients at a mean age of 6.3 years (range, 3.0-15.2 years). Mean follow-up was 13.8 years (range, 5.4-28.7 years) and mean age at last re-evaluation was 22.1 years (range, 13-39 years). Clinical outcomes were assessed based on the Harris Hip Score (HHS) and Postel-Merle d'Aubigné (PMA) score. Radiographs were used to look for a cross-over sign (CO+) and to measure the vertical-centre edge (VCE) and vertical-centre anterior (VCA) angles and the acetabular index (AI). Overcorrection was defined as AI≤0° and/or VCE≥35° and/or VCA≥40° and/or CO+. RESULTS: The HHS and PMA score values were good or excellent for 39 (94%) hips. One or more parameters indicated overcorrection of 33 (80.5%) hips. No significant differences were found between the overcorrected hips and the hips with normal parameters. DISCUSSION: TPO effectively corrects residual acetabular dysplasia. Overcorrection is common in all three planes but has little clinical impact in young adults. The high frequency of overcorrection mandates a careful pre- and intra-operative evaluation of acetabular version. LEVEL OF EVIDENCE: IV, retrospective study.

Lower-limb lengths and angles in children older than six years: Reliability and reference values by EOS® stereoradiography.

BACKGROUND: Lower-limb alignment in children is classically assessed clinically or based on conventional radiography, which is associated with projection bias. Low-dose biplanar radiography was described recently as an alternative to conventional imaging. The primary objective of this study was to assess the reliability of length and angle values inferred from 3D reconstructions in children seen in everyday practice. The secondary objective was to obtain reference values for goniometry parameters in children. HYPOTHESIS: 3D reconstructions can be used to assess the lower limbs in children. MATERIAL AND METHODS: The paediatric reliability study was done in 18 volunteers who were divided into three groups based on whether they were typically developing (TD) children, had skeletal development abnormalities, or had cerebral palsy. The reference data were obtained in 129 TD children. Each study participant underwent biplanar radiography with 3D reconstruction performed by experts and radiology technicians. Goniometry parameters were computed automatically. Reproducibility was assessed based on the intra-class coefficient (ICC) and the ISO 5725 standard (standard deviation of reproducibility, SDR). RESULTS: For length parameters, the ICCs ranged from 0.94 to 1.00 and the SDR from 2.1 to 3.5mm. For angle parameters, the ICC and SDR ranges were 0.60-0.95 and 0.9°-4.6°, respectively. No significant differences were found across experts or radiology technicians. Age-specific reference data are reported. DISCUSSION: These findings confirm the reliability of low-dose biplanar radiography for assessing lower-limb parameters in children seen in clinical practice. In addition, the study provides reference data for commonly measured parameters. LEVEL OF EVIDENCE: IV.

[Resection of navicular bone for severe midfoot deformity in children]. / Résection de l'os naviculaire pour déformation sévère du médio-pied de l'enfant.

PURPOSE OF THE STUDY: The navicular bone lies at the apex of the deformity in severe talipes planovalgus with forefoot abductus, in the residual cavus of congenital talipes equinovarus, in certain cases of congenital convexity, and in certain types of neurological equinovarus. Resection of the navicular bone can be proposed to correct certain deformities. MATERIAL AND METHODS: This series included 15 feet operated on in 13 children from 1980 to 2003. The deformity to be corrected was a residual cavus after surgery for congenital talipes equinovarus (five feet), plantar and medial dislocation of the navicular bone on an acquired equinovarus in non-walking children (three feet), planovalgus with major forefoot abductus in non-walking children (four feet). Among the 13 children in this series, five did not walk (seven feet) and underwent surgery because of skin wounds caused by protrusion of the head of the talus and serious mechanical problems (shoes, ortheses). Mean age at operation was 8.5 years (range 2-16 years). The surgical procedure was part of an overall strategy combining use of ortheses, physiotherapy, and medical management. For congenital equinovarus with residual cavus, naviculectomy was performed after the usual technique for equinovarus when the navicular bone was dislocated above the medial tarsal and prevented reduction of the cavus. After extraperiosteal release, resection of the navicular bone enabled correction of the cavus. The lateral column had to be shortened in order to avoid adductus subsequent to medial-lateral length discrepancy. The same surgical technique was used for acquired equinovarus except that the navicular bone was displaced medially and above the talus. The lateral column had to be shortened. Standard procedures were applied for congenital convex feet before naviculectomy when there was major forefoot abductus after medial tarsal release and tendon lengthenings. The lateral column was not shortened since it was already too short. For planovalgus with forefoot abductus, naviculectomy was combined with release of the calcaneocuboid joint. Fibular tendons were lengthened. RESULTS: Mean follow-up was two years five months (range 5 months-12 years 6 months). For the talipes equinovarus feet, the Méary Toméno angle was 24.4 degrees on average preoperatively and 5 degrees at last follow-up, giving a mean gain of 19.4 degrees . For congenital convex feet, the M5-lateral calcaneal border angle was 29.7 degrees on average preoperatively and 11.7 degrees at last follow-up for a mean gain of 18 degrees . For the planovalgus feet with forefoot abductus, the M5-lateral calcaneal border angle was 32.7 degrees on average preoperatively and 12.2 degrees at last follow-up, for a gain of 20.5 degrees on average; the mean Méary Toméno angle was -30 degrees preoperatively and -3 degrees at last follow-up, for a mean gain of 27 degrees . CONCLUSION: For carefully selected patients, naviculectomy performed in combination with other procedures can provide appropriate correction of severe midfoot deformities in children.

Outcomes of orthopedic surgery in a cohort of 49 patients with X-linked hypophosphatemic rickets (XLHR).

BACKGROUND: X-linked hypophosphatemic rickets (XLHR) is due to mutations in PHEX leading to unregulated production of FGF23 and hypophosphatemia. XLHR is characterized by leg bowing of variable severity. Phosphate supplements and oral vitamin analogs, partially or, in some cases, fully restore the limb straightness. Surgery is the alternative for severe or residual limb deformities. OBJECTIVE: To retrospectively assess the results of surgical limb correction in XLHR (osteotomies and bone alignment except for 3 transient hemiepiphysiodesis). METHODS: We analyzed the incidence of recurrence and post-surgical complications in 49 XLHR patients (29F, 20M) (mean age at diagnosis 6.0 years (± 7.1)). RESULTS: At first surgery, the mean age was 13.4 years (± 5.0). Recurrence was observed in 14/49 (29%) patients. The number of additional operations significantly decreased with age (2.0 (± 0.9), 1.7 (± 1.0) and 1.2 (± 0.4) in children <11 years, between 11 and 15, and >15 years; P < 0.001). Incidence of recurrence seemed to be lower in patients with good metabolic control of the rickets (25% vs 33%). Complications were observed in 57% of patients. CONCLUSION: We report a large series of surgical procedures in XLHR. Our results confirm that phosphate supplements and vitamin D analog therapy is the first line of treatment to correct leg bowing. Surgery before puberty is associated with a high risk of recurrence of the limb deformity. Such procedures should only be recommended, following multidisciplinary discussions, in patients with severe distortion leading to mechanical joint and ligament complications, or for residual deformities once growth plates have fused.

[Orthopedic treatment of spinal deformities in infancy and early childhood]. / Le traitement orthopédique dans la pathologie vertébrale du petit enfant.

Surgical treatment of spinal deformities in infancy and early childhood (before age 6) is often very useful if the lesion is localized and curable by one unique surgery, such as hemivertebra resection and fusion. On the contrary, if the lesion, whether idiopathic or paralytic, is extended to a large part of the spine, early surgical treatment in infancy gives very disappointing results and often worsens the status of the child, especially respiratory function if the lesion is mainly thoracic. The goal of this paper is to explain in detail indications and management of non-surgical treatment of such lesions. These are variable according to localization, etiology, and associated anomalies, and are mainly based on proper casting (often repeated), bracing (often intermittent between casting) and proper respiratory equipment. From time to time, a surgical treatment is locally indicated, but most of the time results are disappointing and the best is to repeat non-surgical treatment until proper definitive arthrodesis can be performed. This approach is not very rewarding for the child and family, but is clearly better than sudden extensive surgery in early childhood with very severe and disastrous results in adulthood. It is our hope that the recommendations and thoughts presented in this paper will help readers to manage young children using the most efficient, non-aggressive, but long-lasting therapy.

Is non-operative management of childhood neurologic cavovarus foot effective?

INTRODUCTION: Neurologic pes cavus is a progressive deformity that is difficult to treat during growth. The present study reports results of non-operative management, based on the pathophysiology of the deformity, by untwisting nocturnal splint, preceded in some cases by untwisting walking cast. The objective was to assess efficacy and impact on indications for surgery. METHOD: Twenty-three children (35 feet) were included. All had neurologic cavovarus foot, which was progressive in 24 feet (69%) (Charcot-Marie-Tooth disease). Mean age at initiation of treatment was 8.8 years. In 13 feet (38%), treatment began with a untwisting walking cast and in 22 (62%) began directly with the splint. RESULTS: Mean follow-up was 4.5 years. Fifteen feet showed very good and 8 good clinical results (65%); 9 children (12 feet) had moderate or poor results, requiring renewed treatment in 11 feet at a mean 4.5 years after initiation of non-operative treatment. Thirteen patients (56.5%, 21 feet) had reached end of growth by last follow-up; 10 of these feet (48%) had good or very good results without surgery. No triple arthrodeses were required. Factors weighing against good outcome comprised young age at treatment initiation and poor compliance with the splint. Primary deformity severity did not affect outcome. CONCLUSION: The present study demonstrated efficacy for non-operative treatment of childhood neurologic cavovarus foot. Surgery was either avoided (in half of the cases followed up to end of growth) or delayed by a mean 4.5 years, allowing a single procedure before end of growth. We recommend initiating non-operative treatment of childhood cavovarus foot, associating untwisting walking cast and untwisting nocturnal splint, as soon as clinical progression is detected and/or Méary angle on lateral X-ray with block reaches 15°. LEVEL OF EVIDENCE: IV.

Congenital dislocation of the knee at birth - Part 2: Impact of a new classification on treatment strategies, results and prognostic factors.

INTRODUCTION: An original classification of congenital dislocation of the knee (CDK) was drawn up, based on neonatal semiology. The objective of the present study was to assess impact on treatment decision-making and prognosis. MATERIAL AND METHODS: Fifty-one CDKs in 40 patients were classified neonatally into 3 types: I, reducible (n=28); II, recalcitrant (n=16); and III, irreducible (n=7). Number of anterior skin grooves, range of motion (RoM), flexion deficit and reduction stability were recorded. Depending on reducibility, treatment comprised: physiotherapy with splints, traction with cast immobilization, or surgery. At follow-up, knees were assessed in terms of RoM and stability. RESULTS: Mean age at first consultation was 5.6 days (range: 0-30). Mean age at follow-up was 9 years (range: 1-26). Physiotherapy with splinting achieved stable reduction in all type-I knees. Five type-II knees (31%) required traction, none of which needed surgery. Four type-III knees (57%) required surgery. Outcome was good or excellent in 82% of type-I knees, good in 68% of type II and poor in all type-III knees. CONCLUSION: The study confirmed the relevance of the present neonatal classification to treatment, with increasing rates of surgical indication and decreasing rates of satisfactory outcome from types I to III. Therapeutic attitude can be graded according to severity of CDK. LEVEL OF EVIDENCE: IV, single-center retrospective series.

Congenital dislocation of the knee at birth - Part I: Clinical signs and classification.

INTRODUCTION: Congenital dislocation of the knee (CDK) is rare, and clinical semiology at birth is not always suitably analyzed. Existing classifications fail to guide treatment. The aim of the present study was to develop a CDK classification for the neonatal period. HYPOTHESIS: A classification based on neonatal severity of clinical signs is easy to implement on simple criteria. MATERIAL AND METHODS: Fifty-one CDKs (40 patients) seen neonatally were included. Three types could be distinguished in terms of reduction and stability: type I, easily reducible CDK, with reduction snap when the femoral condyles pass in flexion, remaining stable in flexion; type II, "recalcitrant" dislocation, reducible by posteroanterior "piston" but unstable, with iterative dislocation once posteroanterior pressure on the condyles is relaxed; and type III, irreducible. The number of anterior skin grooves, global range of motion, flexion deficit and reduction stability were noted for each type. RESULTS: Mean age at first consultation was 5.6 days (range: 0-30). CDK was type I, II and III in respectively 28, 16 and 7 cases. Number of skin grooves, flexion and baseline range of motion were greater in type I than types II and III. CONCLUSION: The present neonatal clinical classification is original, logical and simple. It may be useful for prognosis and guiding treatment. LEVEL OF EVIDENCE: IV, single-center retrospective series.

Centrally adaptations in unilateral idiopathic clubfoot children following conservative treatment.

Adaptations in tiptoe rising were studied in unilateral idiopathic clubfoot (ICF) children, who underwent conservative treatment. The current study concerned 10 ICF children and 10 healthy children of the same range of ages (8-12 year). All ICF children were rated "good" or "very good" treatment results, but showed residual m. Triceps surae atrophy and mild foot alignment flaws. Tiptoe rising task was performed with subjects standing quietly with the feet on separate force platforms. Subjects were instructed to rise onto tiptoes as fast as possible and to maintain the tiptoe erect posture for a few seconds. Surface EMG of muscles Gastrocnemius, Tibialis anterior, Peroneus longus were recorded on both sides, simultaneously with vertical reaction forces (RZ) and centres of pressure (CP) displacements, during a series of 10-15 trials. Foot preferentiality was without influence on the EMG and biomechanical activities of the control group. Although not aware of a deficit in performance, ICF children show less vertical acceleration than healthy children. Timing and magnitude of muscular activities, and Cp and RZ variables of ICF children, evidenced alterations in both affected and sound side, when compared to healthy subjects. Alterations in the affected side activities were well explained by Triceps surae atrophy. Alterations in the sound side were considered as adaptations of central nervous system (CNS), preserving a global symmetry of the task. These results highlight the CNS capacity to adapt even for mild deficiencies. They stressed that it is mandatory to follow ICF children, even if they recovered a normal life.

[Surgical treatment of lumbosacral spondylolisthesis with major displacement in children and adolescents: a continuous series of 20 patients with mean 5-year follow-up]. / Le traitement chirurgical du spondylolisthésis lombo-sacré à grand déplacement de l'enfant et de l'adolescent.

PURPOSE OF THE STUDY: This retrospective analysis involved a continuous series of twenty cases of lumbosacral spondylolisthesis with major displacement treated before maturity. We compared our experience using a non-instrumented lumbosacral fusion technique with the results of other techniques proposed in the literature. MATERIAL AND METHODS: We reviewed the cases of twenty children and adolescents who underwent surgery in our unit. For each case, we recorded the clinical history and course to last follow-up. X-rays were studied and manual measurements taken of the different parameters used to analyze the spine. Data were recorded in a database for statistical analysis. Sixteen of the twenty cases showed spinal deformation causing lumbalgia, generally associated with radiculalgia. Mean age at surgical treatment was 13 years 3 months, range 7 years 2 months to 17 years 6 months. All of the children has Meyerding stage 3 or 4 displacement associated with lumbosacral kyphosis. Surgical treatment followed a period of progressive reduction by traction and suspension in lordosis using a hammock. All twenty patients underwent posterolateral arthordesis using a cancellous graft between L4 and the sacrum. The fusion was performed after fashioning a thoraco-lumbo-pelvic cast including both thighs in the position of reduction. A complementary time for anterior arthodesis was needed for eight patients. RESULTS: The postoperative period was uneventful in twelve patients. Two children developed intestinal obstruction with a peritoneal bridle. Three children had an L5 radicular deficit and three sphincter disorders. All neurological disorders resolved in a few months. At mean postoperative follow-up of 5 years 3 months, the arthrodesis appeared to be fused in 19/20 cases. Only one patient presented a lucent line in the zone of the bone graft suggesting possible fibrous nonunion. Eighteen patients were symptom free and led a normal life. Two patients complained of moderately bothersome lower back pain. DISCUSSION: Many of the children in our series had major lumbosacral dysplasia with a verticalized sacrum, aggravating the lumbosacral kyphosis. This led to an increased pelvic tilt and decreased sacral slope. Progressive preoperative reduction of the lumbosacral kyphosis allowed conducting the lumbosacral fusion under favorable conditions. We did not open the spinal canal and avoided the mid line in order to protect as much as possible posterior spinal stability and preserve all the bone surfaces receiving the posterolateral graft. We reserved indications for complementary anterior lumbosacral arthrodesis to the most exaggerated cases of lumbosacral kyphosis. The therapeutic program is long due to the progressive preoperative reduction and the strict period of immobilization after surgery. In our experience, this approach allows quality lumbosacral fusion with good correction of the lumbosacral kyphosis. Neurological complications remain frequent and can occur during even slow progressive reduction.

Body equilibrium at the end of gait initiation: importance of ankle muscular force as evidenced in clubfoot children.

This study investigates the importance of ankle muscular force and foot shape on body equilibrium at the end of a first step by means of a comparison between healthy children and children with unilateral clubfoot who showed Triceps surae atrophy. Subjects were asked to initiate gait at different velocities and to perform a few forward-oriented steps. In healthy children, there was a significant increase in the number of positive values of the centre of gravity vertical acceleration at foot contact (Z"HC) as velocity increased without any difference between the preferred and non-preferred stepping foot. These results indicated that ankle muscular forces from the leg of support intervene in braking the downfall of the body, as velocity and step length increase, and that this function does not depend on the subject's lateralization. In comparison with healthy children, clubfoot subjects showed a greater occurrence of low or negative Z"HC values when gait was initiated at a velocity greater than 0.8 m/s. However, except for two of them, there was no difference in Z"HC control between the steps initiated with the sound leg and those initiated with the affected leg. These results indicate that in unilateral clubfoot children, residual musculoskeletal impairment of one leg induces a deficit in equilibrium control as soon as step length needs a significant braking of the body's vertical fall. It is also shown that equilibrium is not limited to the gait period where the affected leg is the body's supporting leg but also when it is the stepping one. This could reflect a global alteration of the body scheme preserving symmetry in the control of both legs.

Rotationplasty after failure of a knee prosthesis for a malignant tumour of the distal femur.

Failure of massive knee endoprostheses implanted for malignant tumours of the distal femur in children presents a difficult problem. We present the results of rotationplasty undertaken under these circumstances in four boys. They had been treated initially at a mean age of 9.5 years for a stage-IIB malignant tumour of the distal femur by resection and implantation of a massive knee endoprosthesis. After a mean period of eight years and a mean of four operative procedures, there was failure of the endoprosthesis because of aseptic loosening in two and infection in two. Function was poor with a mean Musculoskeletal Tumor Society score of 7.5/30, and considerable associated psychological problems. At a mean follow-up of 4.5 years after rotationplasty there was excellent function with a mean score of 27.5/30 and resolution of the psychological problems.

[Replacement arthroplasty of paralytic hip. Apropos of 18 cases]. / Arthroplastie totale de la hanche paralytique. A propos de 18 cas.

PURPOSE: Frequency of hip impairment, with sub-luxation or dislocation, during evolution of neuromuscular diseases depends on intensity and spreading of palsy. At the end of growth or at the beginning of adult life, secondary arthritis can induce pain and lack of mobility. The importance of the chondropathy and irreducible lack of congruence may doom to failure a conservative articular or periarticular surgery. Total hip arthroplasty is an alternative, but the risks of dislocation, ectopic ossifications and infection make often refute this indication. We report our experience of total arthroplasty for paralytic hip, about 18 cases. MATERIALS AND METHODS: We reviewed retrospectively 14 consecutive patients with neuromuscular disease, who had 18 total arthroplasties of paralytic hips. The origin of neuromuscular disease was cerebral for 7 patients (6 cerebral palsy: 4 spastic or athetosic tetraplegias, 1 spastic diplegia, 1 hemiplegia; 1 head trauma), 6 medullar disorders (1 Friedreich disease, 2 acute anterior poliomyelitis, 1 vascular injury, 1 malformative spine with sacral agenesis and 1 cervical spine trauma) and 1 muscular affection (Steinert disease). Mean age of the patient was 40 year old (19 to 64). Mean follow up was 5 years. Intensity and diffusion of weakness were variables, compatible with gait with or without help for 11 patients, and for 3 patients with sitting posture and transfer. The coxopathy, with pain stiffness and vicious attitudes, induced the loss of gait or sitting posture and transfer. The goal of the arthroplasty was the restitution of the initial function. 11 hip had previous surgery, with infection in 2 cases. Arthritis was secondary to hip palsy in 14 cases (4 dislocations, 6 subdislocations, 3 complications of surgery of paralytic hip dislocation in childhood, 1 nervous arthropathy), and independent of palsy in 4 cases (1 femoral head avascular necrosis ans 3 primary arthritis). The prosthesis were LFA Charnley Kerboull in all cases except 1. We used transtrochanteric approach. RESULTS: Mean follow-up is 5.6 years. Functional initial goal has been obtain in all cases. Ectopic ossifications occurred in 3 cases, without functional consequence. One acetabular loosening occurred after 13 years and has been reoperated on. There was no polyethylene wear. We noticed 1 mechanical and 2 chemical femoral loosening. Prosthetic dislocation occurred in 4 cases, always during the 4 post-operative months, without recurrence after this critical period. There were no infection. DISCUSSION: If gait is possible, there is no satisfactory alternative to total hip arthroplasty. In absence of gait, total hip arthroplasty gives also the best functional results. Girdlestone procedure is not indicated because it will induce the loss of transfer and side effects as ascension of proximal femur with recurrence of adduction bringing out pain and sometimes scabs. CONCLUSION: Total arthroplasty of paralytic hip induced restitution of initial function for all patients and an acceptable rate of complication after strict selection of patients and indications, specific operative technique and rehabilitation for each patient. This results encourage us to carry on with this therapeutic orientation.