[Traumatic hip dislocations in children]. / Les luxations traumatiques de la hanche chez l'enfant.

PURPOSE OF THE STUDY: Traumatic hip dislocation is a rare event in children. Appropriate management remains a subject of debate. The purpose of this study was to investigate the epidemiological, therapeutic features of this situation and the long-term outcome after treatment. MATERIAL AND METHODS: This was a retrospective analysis of 15 traumatic hip dislocations collected over a period of 20 years in pediatric patients with at least two years follow-up. We searched for predisposing factors and factors affecting prognosis. RESULTS: The series included 11 boys and three girls, mean age eight years. Dislocation was posterior in 13 hips and anterior in two. Time to reduction was less than 3h in eight cases, 3-6h in five and greater than 6h in two. After reduction, traction was performed in nine children, for 20 days on average, followed in five cases by immobilization for 40 days on average. Five hips were immobilized directly after reduction. We identified two groups by age: group 1 with dislocations in children aged less than six years (seven children) were characterized by low-energy trauma. Dislocation was not associated with other lesions. Predisposing factors (overt ligament hyperlaxity, insufficient superolateral head cover, coax valga) were noted in six children. Reduction was simple. Later treatment consisted in immobilization with a pelvispedious cast for 30-45 days. Group 2 were dislocations in children aged over six years (seven children) victims of high-energy trauma. Associated injuries were frequent. Predisposing factors were not present. At mean 11 years follow-up, all hips are considered normal clinically. The radiograph was normal for 14 hips. In one case, there was a slight coax magna. In three patients, defective femoral head cover persisted. Coxa valga persisted in two patients. DISCUSSION: Traumatic dislocation of the hip joint is rare in very young children, but results from a minimally traumatic event. This suggests the presence of predisposing factors in this category of patients, particularly capsuloligamentary hyperlaxity. After reduction, immobilization can be recommended. Traumatic hip dislocations in children are different from the adult variety due to their rarity, the general absence of associated fractures, easy reduction and better prognosis. The epidemiological and therapeutic features in children older than six years are however similar to those in adults.

[Treatment of bone loss in limbs by bone transport]. / Traitement des pertes de substance osseuse des membres par transport osseux segmentaire.

INTRODUCTION: Ilizarov's segmental bone transport technique is one of the treatments of bone defects. The aim of our investigation was to identify which technical specific features could ensure the success of this surgical option and to analyze the various difficulties and complications inherent in this method. MATERIAL AND METHODS: Our analysis covered a series of nine patients - five males and four females with a mean age of 20 years old - all treated by bone transport between 1996 and 2003. Bone loss was secondary to a traumatism in five cases, to the excision of a tibial congenital pseudoarthrosis in three cases and to an osteomyelitis in one case. Bone defect was reported to be located in the tibial distal metaphysis in seven cases, in the tibial diaphysis in one case and in the distal femoral methaphysis in another case. In most cases, bone transport was performed as revision surgery after previous unsuccessful surgical attempts. The mean length of the bone defect was 4.1cm (range: 2 to 8 cm). A shortening of the limb - ranging 1 to 6 cm - was associated with bone loss in six cases. The average follow-up period was 28 months (range 10 to 96 months). RESULTS: The reported difficulties and technical incidents encountered with this method included one incomplete corticotomy, one distraction which was performed in the wrong direction, and one case of cutaneous invagination and axial deviation of the lower limb. At the end of the distraction phase, union was achieved in all cases. At the end of transport, six patients required supplemental bone grafting of the docking site to improve healing. The average size of bone formation was 4.5 cm (range: 3 to 8 cm). The mean distraction index was 14 days per centimeter. The mean time between external fixation and healing was nine months for eight patients. The mean external fixation index was 57 days per centimeter. No infection at the non-union and distraction site was reported. An axial deviation was observed in four cases. Bony reconstruction was excellent in three cases, good in four cases and fair in two cases. All patients could return to normal activity at the end of the treatment. Functional outcomes were excellent in one case and good in eight cases. DISCUSSION: Ilizarov's segmental bone transport technique is a reliable option for the treatment of bone defects that other surgical procedures failed to manage. However, the different technical difficulties and complications inherent in this method require the need for a meticulous planning, adapted to each surgical case.

[Results of surgical treatment of congenital convex pes valgus (10 non-idiopathic feet)]. / Résultats du traitement chirurgical du pied convexe congénital.

PURPOSE OF THE STUDY: Congenital pes valgus is a rare and complex deformity of the foot raising serious diagnostic and therapeutic challenges. The purpose of our work was to present the surgical procedures used in our series and to analyze outcome. MATERIAL AND METHODS: Ten feet presenting congenital convex valgus treated surgically over a six-year period using the same operative technique were reviewed at minimum five years follow-up. Idiopathic deformities were excluded from this series. Deformities were secondary to arthrogryposis in five feet, a multiple malformative syndrome in four and diastematomyelia in one. The surgical technique used two approaches: a posteromedial incision to release the dorsal flexors, disinsert the tibialis posterior, open the talonavicular joint, release the Achilles tendon and release the posterior tibiotalar capsule; a lateral incision to lengthen the fibular tendons and perform an osteotomy of the anterior process of the calcaneum. A talonavicular pin and a calcaneocuboid pin maintained the correction. The tibialis posterior tendon was reinserted on the anterior aspect of the talonavicular capsule after incision of the dislocation chamber. RESULTS: Outcome was considered good in five cases and fair in five. Outcome was fair in the arthrogyrposis feet. Undercorrection was observed in two feet and valgus flatfoot in three. Talar necrosis occurred in one foot and navicular necrosis in two. DISCUSSION: Simultaneous correction of the different anomalies observed in the congenital convex foot was achieved in this series. The anatomic and functional results were satisfactory. We recommend avoiding overly extensive release in order to decrease the risk of talar and navicular necrosis. It is also important to check the reduction radiographically during the operation. Patients should use an orthesis several months postoperatively to avoid recurrence.

[Septic dislocation of the hip secondary to BCG vaccination]. / Luxation septique de la hanche secondaire à la vaccination par le BCG.

We report a case of septic dislocation of the hip in an eight-month-old infant secondary to BCG vaccination. The usual treatment of septic arthritis with surgical drainage and broad spectrum antibiotics was unsuccessful. Cure was achieved after institution of an anti-tuberculosis treatment and a second surgical drainage. This rare complication of BCG vaccination can develop several months after administration of the vaccine. Diagnosis is often difficult to establish due to the minimal clinical and non-specific clinical expression. Early radiological signs are also non-specific. Identification of the causal agent can be most difficult. Certain diagnosis is generally achieved after biopsy and pathology examination. Despite the attenuated virulence of the vaccine, anti-tuberculosis treatment is indispensable to achieve cure. Surgery drainage alone is insufficient.

Hamatum osteoblastoma.

We report the case of an osteoblastoma of the hamate bone that was successfully treated by curettage. This tumor is very rare in a carpal bone and only nine cases have been reported in the literature. Pathological examination is mandatory before treatment due to the lack of distinctive clinical and radiological features. Osteoblastomas are benign, but potentially aggressive bone tumors. Treatment of the lesion may either be a conservative "intralesional resection" or radical "wide en bloc resection". The latter option, which has non-negligible functional consequences in the wrist, should be reserved for recurrence after curettage but may also be considered a primary immediate alternative for aggressive forms.

Pelvic bone hydatidosis.

Bone hydatid disease is a rare pathology, characterized by its long clinical latency, the absence of radiological specificity as well as its challenging surgical treatment. We report an observation of pelvic bone hydatidosis in a 28-year-old patient, appearing with pain and stiffness of the hip as well as a degenerative aspect on the coxofemoral joint on X-ray. The treatment consisted of an extensive hemipelvectomy with femoro pelvic arthrodesis, completed by medical treatment. The functional result was excellent in spite of a break in the fixation material, which allowed a certain mobility at the proximal end of the femur. Hydatid disease of bone is infiltrating,diffuse, slow, and progressive, all characteristics explaining the often-delayed diagnosis. Medical imaging provides accurate analysis for planning a broad surgical resection. The quality of surgical resection is determined according to the risk of recurrence. Pelvic locations are particularly difficult to treat. After an enlarged and difficult surgical resection, reconstruction remains aleatory and poses many technical problems.

Results of surgical treatment of congenital convex pes valgus (ten nonidiopathic feet).

PURPOSE OF THE STUDY: Congenital pes valgus is a rare and complex deformity of the foot raising serious diagnostic and therapeutic challenges. The purpose of our work was to present the surgical procedures used in our series and to analyze outcome. MATERIAL AND METHODS: Ten feet presenting congenital convex pes valgus treated surgically over a six-year period using the same operative technique were reviewed at minimum five years follow-up. Idiopathic deformities were excluded from this series. Deformities were secondary to arthrogryposis in five feet, multiple malformative syndrome in four, and diastematomyelia in one. The surgical technique used two approaches: a posteromedial incision to release the dorsal flexors, disinsert the tibialis posterior, open the talonavicular joint, release the Achilles tendon and release the posterior tibiotalar capsule; a lateral incision to lengthen the fibular tendons and perform an osteotomy of the anterior process of the calcaneum. A talonavicular pin and a calcaneocuboid pin maintained the correction. The tibialis posterior tendon was reinserted on the anterior aspect of the talonavicular capsule after incision of the dislocation chamber. RESULTS: Outcome was considered good in five cases and fair in five. Outcome was fair in the arthrogryposis feet. Under correction was observed in two feet and valgus flatfoot in three. Talar necrosis occurred in one foot and navicular necrosis in two. DISCUSSION: Simultaneous correction of the different anomalies observed in the congenital convex foot was achieved in this series. The anatomic and functional results were satisfactory. We recommend avoiding overly extensive release in order to decrease the risk of talar and navicular necrosis. It is also important to check the reduction radiographically during the operation. Patients should use an orthesis for several months postoperatively to avoid recurrence.