[Congenital pseudarthrosis of the forearm. Report of two cases and review of the literature]. / Pseudarthrose congénitale de l'avant-bras. A propos de deux cas et revue de la littérature.

Congenital pseudarthrosis of the forearm represents a rare entity which is often associated with neurofibromatosis type I. Isolated pseudarthrosis of the ulna is the most frequent deformity, followed by pseudarthrosis of the radius and both forearm bones. The treatment of these deformities remains difficult: conventional bone grafts rarely lead to complete fusion. The reconstruction by a vascularized fibular graft represents the treatment of choice if the radial head is not dislocated. This procedure allows restoration of a balance between radius and ulna during growth. The presence of a vascularized graft enhances the potential for bony fusion in a fibrous environment. In cases of isolated ulna pseudarthrosis, a luxation of the proximal radial epiphysis may occur when the ulnar deformity increases with time. The single-bone forearm represents a salvage procedure that creates a stable upper limb with a satisfactory wrist and elbow function. The two clinical cases of a pseudarthrosis of both forearm bones and of an ulna pseudarthrosis are presented.

Volumetric thoracic growth in children with moderate and severe scoliosis compared to subjects without spinal deformity.

Idiopathic scoliosis leads to a three-dimensional thoracic deformity. The purpose of this study is to measure thoracic dimensions and volume related to growth and to verify the influence of moderate and severe scoliosis. 176 children (36 boys, 140 girls; 4-16 years) with scoliosis <45 degrees and 17 patients (2 boys, 15 girls) with scoliosis >65 degrees were compared to 239 children without spinal deformity (97 boys, 142 girls) using an optical system. Thoracic volume, perimeter, anterior-posterior and transversal diameters, T1-T12 and sternal lengths were calculated. These measurements were related to age and sitting height. Thoracic volume (3-16 dm(3)) did not differ significantly over growth between reference and moderate scoliosis groups. At 4 years, it represents 33%, at 10 years it represents 55% of its volume compared with age 16. It triples from 4-16 years and doubles during puberty. In severe scoliosis, the age related thoracic volume was always lower than volumes in reference and moderate scoliosis groups. During growth, the transversal diameter corresponds to 30%, the anterior-posterior diameter represents 20% and the thoracic perimeter 100% of sitting height. In severe lordoscoliosis the anterior-posterior diameter represents less than 20%. Scoliosis <45 degrees does not influence thoracic volume significantly. Severe deformities seem to inhibit volumetric growth. Thoracic parameters should be related to growth parameters such as sitting height rather than age because of possible height variations in one age section. The established relationships offer a reliable orientation of thoracic proportions. They help to understand the global deformity and represent a baseline for surgical treatment using vertical expandable prosthetic titanium ribs.

[Selective dorsal T1-T6 fusion of the thoracic spine and effects on thorax growth: experimental study in prepuberal New Zealand White rabbits]. / Influence de l'arthrodèse vertébrale dorsale sélective T1-T6 sur la croissance thoracique: étude expérimentale chez des lapins New Zealand White prépubertaires.

PURPOSE OF THE STUDY: The purpose of this study is to assess the consequences brought by selective dorsal arthrodesis of thoracic spine (T1-T6) to the growth of spine and thoracic volume in operated and sham-operated New Zealand White rabbits, between prepubertal age and the end of somatic growth, through the study of computerised tomography (CT) scans periodically carried out on them after arthrodesis surgery. MATERIAL AND METHODS: Nine female rabbits were subjected to surgery for selective dorsal arthrodesis of the upper thoracic spine and three were sham-operated. Surgery was performed at age nine weeks, before the onset of puberty. Two "C"-shaped titanium bars were placed beside the spinous processes of the thoracic vertebrae to obtain a selective posterior arthrodesis of the first six thoracic vertebrae. Under general anesthesia, three CT scans were performed, 10 (t1), 55 (t2) and 139 (t3) days after surgery. Measures were obtained by Myrian Pro software for three different groups: group 1 with complete fusion, group 2 with incomplete fusion, group 3 sham-operated. RESULTS: The total dorsal and ventral lengths of thoracic vertebral bodies in the spinal segment T1-T6 was smaller in group 1 and group 2 than in group 3, whereas no differences were observed between the three groups in the T7-T12 segment. The average of the dorsoventral/laterolateral thoracic diameter ratio at fused levels was less than 1 in group 1 as well as in group 2; on the contrary, in group 3 it was greater than 1. The sternum and lung volume grow less. CONCLUSIONS: Vertebral arthrodesis in the treatment of progressive idiopathic scoliosis in prepubertal patients is not ideal, but is still a choice in treating major deformities of the spine. Postoperative assessment of spinal deformity is essential, feasible and recordable through CT scans. Dorsal arthrodesis in prepubertal rabbits changes thoracic growth patterns. In operated rabbits, the dorsoventral thoracic diameter grows more slowly than the laterolateral thoracic diameter. The sternum, the total lengths of thoracic vertebral bodies in the spinal segment T1-T6 and lungs grow less. The Crankshaft phenomenon is evident at the fused vertebral levels where there is a reduction of thoracic kyphosis.

Ultrastructural aspects of nerves, bones, and vessels in hereditary sensory neuropathy.

This study concerns two children, from the same otherwise normal family, presenting progressive spontaneous amputations of the limbs, suggesting peripheral hereditary sensory neuropathy. Samples from the distal nerves and vessels and the distal tibial epiphyses were examined ultrastructurally. The nerves showed signs of degeneration, and a typical bone necrosis, without osteoclasts, was observed in the 2 cm margin of the samples. Simultaneous modifications of the vessels suggest a neurally initiated vascular reflex resulting in bone destruction. Theories that might explain the observations are discussed.

Neonatal surgery in clubfoot.

Neonatal surgery for clubfoot is conducted according to the following rules: One must work as close to the lesions as possible. It is important to avoid going beyond abnormal tissues. Dissection should be precise and economical. Opening of Lisfranc's joint or sectioning of the medial ligament must be avoided. One must operate with maximal accuracy. All areas of fibrosis must be excised, but care must be taken not to enter the interarticular space. If a bone deformity is present, one must accept an incomplete correction. One must act as soon as possible. This is the inverse of classic management in which orthopedic surgery was postponed. We prefer early surgery followed by intensive postoperative rehabilitation.

Final evaluation of clubfoot.

After analyzing the multiple evaluations described in the literature, we propose an evaluation that can be used during growth. The global score is based on 50 points. The normal foot is scored 0. The functional evaluation (passive motion, muscle function, and gait analysis) is based on 28 points. The morphology is based on 12 points. The radiographic analysis is scored on 10 points. The final evaluation score is linked to the initial classification at birth. The gain during the treatment is the difference between the score at birth and the score of the final evaluation. It is noted as a percentage.

Classification of clubfoot.

Clubfeet must be classified according to severity to obtain reference points, assess the efficacy of orthopaedic treatment, and analyze the operative results objectively. A scale of 0-20 was established on the basis of four essential parameters: equinus in the sagittal plane, varus deviation in the frontal plane and derotation around the talus of the calcaneo-forefoot (CFF) block and adduction of forefoot on hindfoot in the horizontal plane. Four grades of clubfeet can be individualized: (a) Benign feet so-called "soft-soft feet," grade I, similar to postural feet, with a score of 5 to 1 (these mild feet must be excluded from any statistics as they tend to increase good results); (b) moderate feet, so-called "soft > stiff feet," grade II (reducible but partly resistant, with a score of 5-10); (c) severe feet, so-called "stiff > soft feet," grade III (resistant but partly reducible, with a score of 10-15); and (d) very severe, pseudoarthrogryposic feet, so-called "stiff-stiff feet," grade IV (score of 15-20 points). To avoid risks of errors, our method is based on a very complete checklist and on diagrams. Our training material inculdes an audiovisual package.

Orthopaedic treatment and passive motion machine: consequences for the surgical treatment of clubfoot.

The efficacy of orthopaedic treatment and its influence on clubfoot surgery has never been truly demonstrated. In the unsorted mass of clubfeet treated, it is difficult to determine exactly how effective orthopaedic treatment is for severely affected feet. If properly performed, perfectly synchronized, and supported by a Kinetec machine, such treatment can noticeably reduce the rate of operation and, when operation is still required, reduce its extent. In grade II soft > stiff feet with scores of 5-10, Kinetec-supported orthopaedic treatment is extremely effective. Operation is required in 32% of cases only, and posterior surgery is often sufficient. Lateral release, in this category, is never required. In grade III stiff > soft feet, with scores of 10-15, the efficacy of orthopaedic treatment associated with the Kinetec machine is far from negligible and operation most often includes posterior and medial release (PMR), variably associated with plantar release. Lateral release is exceptional (15%), and operation is necessary in 75% of cases. In grade IV stiff = stiff feet, with scores of 15-20, orthopaedic treatment with the Kinetec machine has a true, though limited, effect. In this category, operation is necessary in 90% of cases. Lateral release is performed in 50%. In the postoperative period, orthopaedic treatment combined with use of the Kinetic machine must be continued. Orthopaedic treatment coordinated with use of the machine has considerably shortened the duration of plaster cast immobilization; 2 months when operation included posterolateral-medial (PLMR) release or PMR, and only 1 month when operation was posterior release (PR). The machine has noticeably changed the results and has indisputably influenced operation on the whole.

Bilateral Legg-Calvé-Perthes disease: different from unilateral disease?

Twenty-five patients or 50 hips with bilateral Legg-Calvé-Perthes disease were reviewed at skeletal maturity in the orthopaedic departments of Leuven, Belgium, and Montpellier, France. The two groups were very similar as to age at onset of the disease, severity of involvement, and classification at skeletal maturity. The results seem to indicate that bilateral disease runs a more severe course as compared with unilateral Legg-Calvé-Perthes disease. Eighty percent presented with a Catterall group III and IV and Herring classification B and C. Forty-eight percent rated as Stulberg 4 and 5 at skeletal maturity.

[Assessment of carpal bone maturation by imaging: an alternative to bone age determination or a complementary study?]. / L'évaluation de la maturation des os du carpe par analyse d'image: une alternative à l'âge osseux ou un outil complémentaire?

Radiographic evaluation of skeletal maturation with or without automated systems relies on the comparison between the radiographic appearance of portions of a child's skeleton and the standardized appearance in a comparable population of children. Assessment of skeletal maturation using image analysis of wrist computerized-assisted tomography is a quantitative method allowing for measurements of the volume of each carpal bone, the axis of inertia, and the mean bone density. Morphological modifications of carpal bones are characterized by quantitative data relating to the length of the axis of inertia and the volume. Imaging is a potentially useful method for carpal bone assessment during growth.

[Scoliotic malformations with or without associated occult spinal dysraphia. A study in 82 children. Current radiological techniques, indications and findings]. / Scolioses malformatives, avec ou sans dysraphie spinale occulte. A propos de 82 observations de l'enfant. Techniques radiologiques actuelles, séméiologie et indications.

The possible association of spinal dysraphia with scoliotic malformations was studied in 82 children. Scoliotic malformations are not always the result of dysraphic malformations (diastematomyelia, hydromyelia, intrathecal lipoma, medullary cone ectopia). Recognition of dysraphic scoliotic malformations from among other types of scoliotic malformations can be accomplished before myelography by detecting vertebral malformations on standard films and, if necessary, by computed tomography. Segmental vertebral malformations, affecting vertebral bodies only, do not appear to arise from malformations of nerves. On the contrary, however, dysraphic lesions are always associated with vertebral neural malformations. Of currently employed techniques, only myelography with metrizamide, followed by computed tomography, gives the maximum amount of data concerning the lesions. Even the association of these two techniques does not demonstrate the presence of certain intrathecal fibrous lesions, due to lack of resolution.

[Prevention of congenital hip dislocation. To screen or not to screen?]. / La prévention de la luxation congénitale de hanche. "To screen or not to screen?"

After a historical review and a description of the current situation in Western-Europe, the author analyzes certain "myths" and "preconceived notions" which, although generally accepted, are useless. The author reports on valuable clinical techniques in the prevention of CDH.

[Three-dimensional analysis of the hip during growth]. / Analyse tridimensionnelle de la hanche en croissance.

Ultrasonography provides a genuine breakthrough in the diagnosis of congenital dislocation of the hip and also helps considerably in evaluating the evolution and treatment. Current tridimensional analysis techniques, as described in this article, have revolutionized imaging. Operative situations may be simulated by a computer. Congruence, concentricity and coverage of the head may be evaluated.

[Fibrocartilaginous dysplasia and tibia vara in young children: presentation of 3 new cases with spontaneous resolution and review of the literature]. / Dysplasie fibrocartilagineuse focale et tibia vara unilatéral du jeune enfant: présentation de 3 nouveaux cas à résolution spontanée et revue de la littérature.

Focal fibrocartilaginous dysplasia is a rare and benign condition associated with unilateral tibia vara in toddlers. Three additional cases are reported in children aged 17, 18 and 26 months with spontaneous resolution. The authors discuss, based on a meta-analysis, the natural history of the disorder and review the diagnostic and pathophysiological problems. Since spontaneous remodeling of varus angulation and healing of the bony defect can be expected, biopsy and surgical intervention should be avoided.

[Is treatment of C.D.H. by progressive reduction by traction still advisable? (author's transl)]. / Que reste-t-il de l'extension continue dans le traitement de la luxation congénitale de hanche.

The authors analyse the results that they have obtained in the treatment of C.D.H. either by conservative or surgical methods. The prevention of osteochondritis remains the main worry. However traction leads to long-lasting immobilization and sometimes it is not sufficient. The authors think that osteochondritis may be related to hyper-pressure on the femoral head or to lesions of the vascular pedicle and that in some cases shortening of the femur or tenotomies may allow a decrease of the plaster cast period. The indications on capculotomy, rotation osteotomy, salter osteotomy are discussed. It is concluded that the periods of traction and plaster cast immobilization should be lessened as much as possible.

[Technics and strategy in the treatment of severe paralytic scoliosis]. / Techniques et stratégie dans le traitement de la scoliose paralytique grave.

Sixty-three paralytic scolioses with severe disability have been treated between 1973 and 1982. Fifty-two were due to poliomyelitis. The average angular deformity was 95.8 degrees and was related to delay in treatment and rapid progress of the curve. All cases were operated on. Spine fusion was performed either by the anterior approach (Dwyer or V.D.S.) or by a posterior approach (Harrington or Harrington - Luque). The pre-operative management was based on Cotrel or Halo traction. There were several complications - three non-unions, three neurological impairments, and nine cases of sepsis. It was concluded that the pre-operative management should be as short as possible, that the spine fusions should be done systematically and that any paralytic scoliosis increasing by more than 10 degrees a year between the ages of 8 and 10 years should be operated on early. This type of treatment should lower the incidence of severe disability and allow good functional and educational rehabilitation. The degree of diminished growth of the spine was moderate.

[Surgical treatment of dislocated hips after 5 years of age]. / Le traitement chirurgical de la hanche luxée après l'âge de 5 ans.

Fifty dislocated hips after the age of 5 were treated between 1975 and 1980. The surgical procedures performed combined tenotomy of the iliopsoas and adductor muscles, shortening of the femur, capsulorraphy and a pelvic osteotomy usually for re-orientation (Salter procedure) and rarely for widening of the acetabulum (Chiari procedure). It is thought that tenotomies and femoral shortening were more efficient than pre-operative traction which produced osteoporosis. However post-operative traction was used. In some cases plaster cast immobilisation was not used. The advantages of this technique were an acceleration of the surgical programme, better articular stability and early mobilisation. Osteochondritis and post operative stiffness were rare. The average range of movement included 90 degrees of flexion and lumbar balance was the most significantly improved factor. This type of surgical procedure aims to slow the development of coxarthrosis but it cannot diminish the risk. The limit of age for such treatment appears to be 10 years. After that, the indications need to be assessed carefully.

[Fractures of the intercondylar eminence of the tibia in children. Apropos of 25 cases with a 1-20 year follow up]. / Fractures de l'éminence intercondylaire du tibia de l'enfant. A propos de 25 cas avec un recul de 1 à 20 ans.

PURPOSE OF THE STUDY: This study tries to clarify the diagnostic strategy in intercondylar eminence fractures of the tibia and aids the deduction of therapeutic options based on the analysis of the long-term morbidity of anterior laxity. MATERIAL AND METHODS: This retrospective, monocentric study of 25 children with a mean age of 11.8 years (7-15 years) was performed with an average follow-up of 7.2 years (1-20 years). Fractures are itemized with Meyers-McKeever modified by Zaricznyj and Zifko-Gaudernak classifications. Conservative treatment (16 patients) consisted of hemarthrosis aspiration, ligament examination, manipulation into extension and cast immobilization under general anesthesia. Surgical treatment (9 patients) consisted of wire suture fixation (4 times), wire suture fixation held by a screw (3 times) and direct screw fixation (2 times). Four patients were lost to follow-up. Patients were evaluated with the Lysholm (21 patients) and IKDC (15 patients) scores systems. Anterior laxity was checked with a KT-1000 arthrometer. Antero-posterior and lateral X-rays were performed. The statistical analysis was carried out with Mann-Whitney and Fischer tests. RESULTS: There are 18 good or very good results and only 3 medium with the Lysholm score and 5 knees graded A, 9 graded B and 1 graded C with the IKDC score. Mean anterior laxity is 1.86 mm (0 to 4 mm) after conservative treatment and 1.5 mm (-1 to 4 mm) after operative treatment. 5 patients have an anterior laxity and only 2 an anterior instability. No arthritic lesions, 1 nonunion, and 11 malunions have been observed, mainly after conservative treatment. DISCUSSION: Ligament examination under general anesthesia is useless for displaced fractures and dangerous for those were not displaced. Diagnostic arthroscopy is not yet allowed. Magnetic Resonance Imaging is useful to explore osteochondral fractures and symptomatic meniscal lesions. Laxity is the consequence of anterior cruciate ligament elongation. CONCLUSION: The diagnosis of these fractures rests on a simple radio-clinical examination to determinate the exact position, the displacement and the size of the osteochondral fragment in order to choose the best treatment. Conservative treatment will be chosen preferentially because of a poor long-term morbidity. Treatment will be surgical, preferably arthroscopic, in the others cases.

[Knee arthroscopy in children]. / Arthroscopie du genou de l'enfant.

PURPOSE OF THE STUDY: Between 1990 and 1998, 110 knee arthroscopies were performed in children. We analyzed the epidemiology and diagnostic data and studied the correlation between clinical and radiographic findings and the final diagnosis after arthroscopy in order to establish a consensus on use of knee arthroscopy in children. MATERIAL AND METHODS: We made a retrospective analysis of 110 knee arthroscopies performed in children, classing the patients in three age groups: 0-5 years, 5-10 years, 10-17 years. Clinical and radiological findings were compared with the arthroscopy findings. RESULTS: One or more arthroscopies were performed in 56 boys and 48 girls. Mean age at the time of the procedure was 12 years 4 months. There were 11 children aged 0-5 years, 14 aged 5-10 years and 85 aged 10-17 years. The main pathology was arthritis in the 0-5 year and 5-10 year age groups. Trauma was more frequent in the older children. Knee arthroscopy was found to be normal in 19 cases. DISCUSSION: For most surgery teams, arthroscopy is indicated for arthritis of the knee. Arthroscopy may also be needed for hemarthrosis. In these contexts, arthroscopy is both a diagnostic and therapeutic procedure. Our analysis demonstrates that emergency arthroscopy is only warranted for free floating osteochondral fractures and fractures of the tibial articular surfaces, with the exception of the tibial spines. Arthroscopy may be performed later in other cases after careful physical examination and radiographic series. We had 19 normal arthroscopies and 10 that showed femoropatellar chondropathies and plicas that could explain knee pain. We recommend arthrography before arthroscopy to avoid unnecessary procedures. CONCLUSION: Arthritis of the knee is an excellent indication for arthroscopy. Painful and acute hemarthrosis requires attentive physical exams and x-rays before making the decision for surgery.

[Our indications in surgical treatment of supra-condylar fractures of the femur]. / Nos indications dans le traitement chirurgical des fractures supra-condyliennes du fémur

The treatment of supracondylar fractures of the femur should be surgical. The authors consider the requirements of a strict technic of osteosynthesis. The use for this purpose: either a plate and strip, or a plate and screw, and justify their respective indications.