Respiratory mechanics and gas exchanges in the early course of COVID-19 ARDS: a hypothesis-generating study.

RATIONALE: COVID-19 ARDS could differ from typical forms of the syndrome. OBJECTIVE: Pulmonary microvascular injury and thrombosis are increasingly reported as constitutive features of COVID-19 respiratory failure. Our aim was to study pulmonary mechanics and gas exchanges in COVID-2019 ARDS patients studied early after initiating protective invasive mechanical ventilation, seeking after corresponding pathophysiological and biological characteristics. METHODS: Between March 22 and March 30, 2020 respiratory mechanics, gas exchanges, circulating endothelial cells (CEC) as markers of endothelial damage, and D-dimers were studied in 22 moderate-to-severe COVID-19 ARDS patients, 1 [1-4] day after intubation (median [IQR]). MEASUREMENTS AND MAIN RESULTS: Thirteen moderate and 9 severe COVID-19 ARDS patients were studied after initiation of high PEEP protective mechanical ventilation. We observed moderately decreased respiratory system compliance: 39.5 [33.1-44.7] mL/cmH2O and end-expiratory lung volume: 2100 [1721-2434] mL. Gas exchanges were characterized by hypercapnia 55 [44-62] mmHg, high physiological dead-space (VD/VT): 75 [69-85.5] % and ventilatory ratio (VR): 2.9 [2.2-3.4]. VD/VT and VR were significantly correlated: r2 = 0.24, p = 0.014. No pulmonary embolism was suspected at the time of measurements. CECs and D-dimers were elevated as compared to normal values: 24 [12-46] cells per mL and 1483 [999-2217] ng/mL, respectively. CONCLUSIONS: We observed early in the course of COVID-19 ARDS high VD/VT in association with biological markers of endothelial damage and thrombosis. High VD/VT can be explained by high PEEP settings and added instrumental dead space, with a possible associated role of COVID-19-triggered pulmonary microvascular endothelial damage and microthrombotic process.

Modulation of the immunosuppressive activities by blastocoelic fluid during rabbit pregnancy.

Temporal variation in immunosuppressive activity was determined in biological samples such as embryo-foetal fluids (blastocoelic- or amino-allantoic fluid) and blood collected from pregnant and pseudopregnant rabbits. Each of the fluids to be analyzed was pre-incubated with mitogen stimulated human lymphocytes for 48 h and then inhibition of [3H]thymidine incorporation or IL-2 receptor expression was estimated. Both means of assessing immunosuppression indicated variations in the suppressive activity throughout pregnancy. This was observed in embryo-foetal fluids but not in autologous peripheral blood nor in homologous pseudopregnant blood. At days 9-13 of pregnancy, the immunosuppressive effects of blastocoelic fluids were higher than that of the autologous sera, reached a peak at days 12 and 13 and declined thereafter, to reach the lowest levels. In order to further characterize the biological activity of day-12 blastocoelic fluid and autologous serum, they were submitted to ultracentrifugation. No suppressive activity could be demonstrated in the lipoprotein fractions. But all the activity was found in the protein fraction. Precipitation with cold ethanol confirmed that the biologically active compound was a protein. Furthermore, results obtained after ultrafiltration suggest biologically active compounds of high mol. wt (greater than 300 kDa). From the above findings, we can suggest that in the rabbit, there is no pregnancy specific systemic immunosuppression. We can also infer that (1) the immuno-tolerance of the mother towards the embryo is more due to a localized effect; (2) this effect decreases with the progression of gestation and (3) a high mol. wt factor is responsible for the immunosuppression.

Platelet-activating factor acetylhydrolase activity in peritoneal fluids of women with endometriosis.

OBJECTIVE: To investigate whether platelet-activating factor acetylhydrolase may play a role in the pathophysiology of endometriosis. METHODS: Peritoneal fluids were obtained at laparoscopy from eight fertile women without endometriosis and 12 women with mild endometriosis. Platelet-activating factor acetylhydrolase activity was assayed in serum and peritoneal fluid by the release of 3H-acetate from [3H]-platelet-activating factor during a 15-minute incubation. RESULTS: Platelet-activating factor acetylhydrolase activity (mean +/- standard error of the mean) was significantly lower (P < .01) in peritoneal fluids from women with mild endometriosis (29.5 +/- 2.7%) than in controls (39.9 +/- 3.4%). The platelet-activating factor acetylhydrolase-cholesterol and -albumin ratios were also significantly lower in peritoneal fluids of women with endometriosis compared with controls (P < .006 and P < .012, respectively). CONCLUSION: These data suggest that mild endometriosis is associated with decreased platelet-activating factor acetylhydrolase activity in peritoneal fluid.

Platelet-activating factor acetylhydrolase in human seminal plasma.

OBJECTIVE: To search for the presence of platelet-activating factor (PAF) acetylhydrolase activity in human seminal plasma. DESIGN: Experimental. SETTING: Reproductive laboratory in a university-affiliated hospital research center. PARTICIPANTS: Human male volunteers were selected on the basis of apparent normal health. RESULTS: Human seminal plasma contained significant levels of PAF-acetylhydrolase activity. Enzymatic hydrolysis of PAF displayed typical kinetics and was a calcium-independent process. Platelet-activating factor acetylhydrolase in seminal plasma was associated with a very high-density lipoprotein fraction. Enzymatic activity was independent of sperm count and motility. CONCLUSION: Human seminal plasma contains significant levels of PAF acetylhydrolase. This enzyme may be an important factor in the regulation of PAF concentration and activity.

Effect of platelet-activating factor, lyso-platelet-activating factor, and lysophosphatidylcholine on sperm motion: importance of albumin for motility stimulation.

OBJECTIVES: To determine the effect of platelet-activating factor (PAF), the PAF derivative lyso-PAF, and lysophosphatidylcholine on in vitro sperm motility and to determine the role of albumin in this interaction. DESIGN: Washed human spermatozoa were exposed to a range of PAF, lyso-PAF, or lysophosphatidylcholine concentrations, supplemented with different albumin concentrations, and the effect on sperm motion was quantified with a computer-assisted motion analysis. The metabolism of these compounds by spermatozoa was also assessed. SETTING: University research laboratory. PATIENTS, PARTICIPANTS: Semen samples were obtained from donors and patients attending an infertility clinic. INTERVENTIONS: Human spermatozoa were incubated with PAF, lyso-PAF, or lysophosphatidylcholine at 10(-11) to 6 x 10(-4) M, with 0% to 1.2% albumin, and motility was evaluated at different time periods from 5 to 240 minutes. Tritiated PAF, lyso-PAF, or lysophosphatidylcholine was incubated with spermatozoa, and the metabolites were separated and quantified by thin-layer chromatography (TLC). MAIN OUTCOME MEASURES: Sperm motion characteristics, including the percentage of motile spermatozoa, velocity, and linearity, and sperm viability were determined. The metabolism of PAF, lyso-PAF, and lysophosphatidylcholine by spermatozoa was also studied. RESULTS: Fifty micromolar of PAF and 100 microM lyso-PAF, supplemented with 0.3% albumin, increased sperm linear velocity by 41% +/- 5% (+/- SEM) and 44% +/- 5% and curvilinear velocity by 17% +/- 3% and 21 +/- 3%, respectively. Lysophosphatidylcholine had a similar effect but only at 22 degrees C and not 37 degrees C. In the absence of albumin, neither PAF, lyso-PAF, or lysophosphatidylcholine induced increases in sperm motion. Lysophosphatidylcholine and lyso-PAF are not detectably metabolized by spermatozoa, whereas 12.5% +/- 1.2% of PAF is hydrolyzed to lyso-PAF in 1 hour. CONCLUSION: Platelet-activating factor, lyso-PAF, and lysophosphatidylcholine independently stimulate sperm linear and curvilinear velocity. This action requires albumin. These compounds may be of use in the treatment of asthenozoospermic males.

Male infertility associated with round-headed acrosomeless spermatozoa.

The properties of spermatozoa with round head syndrome in four unrelated patients are reported. The findings were as follows: (1) Electron microscopy demonstrated that all spermatozoa lacked an acrosome and postacrosomal sheath. (2) Acrosin activity was only 1% to 6% of that found in sperm obtained from fertile donors. (3) Phospholipase A2 activity was not significantly different from that of spermatozoa from donors of unknown fertility. (4) Electrophoresis of whole sperm extracts revealed deficiencies in major protein bands. (5) The round-headed spermatozoa failed to bind or penetrate the vitellus in the egg penetration test. (6) The rates of chemically induced nuclear chromatin decondensation of round-headed spermatozoa suggest that the acrosome content is not involved in this process.

Human embryos produce transforming growth factors alpha activity and insulin-like growth factors II.

OBJECTIVE: To assess whether growth factors are produced by early human embryos in culture. DESIGN: We studied various growth factors in the culture media of human embryos (n = 6) cultured from days 3 to 8 after fertilization. MAIN OUTCOME MEASURES: Four growth factors were measured: Insulin growth factors I and II (IGF-I and IGF-II), epidermal growth factor (EGF) and transforming growth factor alpha (TGF alpha) activity. RESULTS: Nonconditioned INRA Menezo B2 (Biomerieux, S.A., Paris, France) culture medium contained significant levels of TGF alpha activity (5.2 ng/mL) and low levels of IGF-I (1.02 ng/mL) and IGF-II (2.8 ng/mL), whereas EGF was below detection of our assay. With human embryo, the culture media contained lower TGF alpha activity on days 3 and 4 after fertilization (2.5 ng/mL and 2.8 ng/mL, P less than 0.05). From days 5 to 8 after fertilization, a significant increase in TGF alpha activity and IGF-II was detected (TGF alpha activity: day 5: 3.7 ng/mL; day 6: 4.4 ng/mL; day 7: 6.4 ng/mL; day 8: 8.4 ng/mL) (IGF-II: day 5: 3.4 ng/mL; day 6: 3.1 ng/mL; day 7: 4.1 ng/mL; day 8: 4.2 ng/mL). Epidermal growth factor was undetectable, and IGF-I did not vary significantly. CONCLUSION: Transforming growth factor alpha activity and IGF-II are produced by human embryos in culture at a time when they could play a role in morula to blastocyst transformation.

Effect of lysoplatelet-activating factor on human sperm fertilizing ability.

OBJECTIVE: To evaluate the penetration rates in the hamster zona-free oocyte sperm penetration assay (SPA) after exposure of spermatozoa to lysoplatelet-activating factor (LPAF) and lysophosphatidyl choline (LPC). DESIGN: Washed human spermatozoa were exposed to 100 microM of LPAF or LPC, followed by the assessment of their fertilizing ability using the SPA. The percentage of penetration, the sperm binding in the SPA, the percentage of motile spermatozoa, and the acrosome reaction rates were quantified. SETTING: Private research and university laboratories. PATIENTS, PARTICIPANTS: Fresh and frozen semen samples from fertile donors with proven fertility were used as well as fresh semen from infertile patients attending a fertility clinic. All the infertile patients had abnormal semen analysis. INTERVENTIONS: Human spermatozoa were incubated for 90 minutes in the presence or absence of LPAF or LPC at 100 microM with 0.3% albumin in Ham's F-10 (GIBCO, Dorval, Quebec, Canada), and their fertilizing ability was evaluated using the SPA. The effect of these lysophospholipids on the percentage of acrosome reaction was evaluated with a fluorescent microscopy technique. RESULTS: The penetration rates of the SPA in male factor increased significantly from 3% +/- 6% with controls to 19% +/- 9% and 34% +/- 22% after incubation with LPC and LPAF, respectively. Sperm-oocyte binding was not significantly increased in this group. Sperm penetration assay penetration rates were also increased in fertile cryopreserved spermatozoa with LPC and LPAF. In this group, the acrosome reaction was significantly increased from 2% +/- 1% in controls to 10% +/- 6% and 8% +/- 3% after incubation with LPC and LPAF, respectively. CONCLUSION: Lysoplatelet-activating factor and LPC independently increased the penetration rate of spermatozoa and the percentage of acrosome reaction. Lysophosphatidylcholine and LPAF may be beneficial in the treatment of spermatozoa with male factor infertility and may increase fertilization rates in IVF.

Bone growth after lengthening of the lower limb in children.

Femoral and tibial growth was studied in 6 children undergoing a femoral lengthening and 28 children a tibial lengthening. Growth of both femurs and tibiae was evaluated for 3 years both before and after the procedure. No significant growth disturbance was noted in femoral lengthenings of 14%. However, growth variations were constant after tibial lengthening of 18% on the average and could be correlated to the amount of lengthening. The consequences of these changes are limited in terms of final limb length because overgrowth of the femur often compensates for growth retardation of the tibia when tibial lengthening is less than 18%. Experimental and clinical studies assert that lengthenings of more than 30% can result in significant and definite growth retardation of the lengthened bone.

Assessment and neurologic involvement of patients with cervical spine congenital synostosis as in Klippel-Feil syndrome: study of 19 cases.

We reviewed 19 children and adolescents with cervical spine congenital synostosis as in Klippel-Feil syndrome (KFS), with an average follow-up of 12.5 years. We paid particular attention to neurologic complications associated with cervical spine abnormalities. Five patients were affected by neurologic complications; four underwent a surgical procedure; and 14 had no neurologic finding. Two had hypermobility at one level, and one had hypermobility at two levels. We found that the more numerous the occipito-C1 abnormalities, the more significant the neurologic risk. In contrast, this risk was not related to the number of "mobile blocks" or to age. Various mechanisms of neural complications have been studied in the literature: medullary abnormality, spinal instability, narrowing of the cervical canal, and vascular dysfunction. Surgery is usually thought to be required in cases with neurologic complications. The indication for surgery is, however, less clear in cases of pure instability without neurologic involvement because surgery is likely to increase the future risks at mobile disks either above or below the fuse level. Careful clinical and radiologic observation is necessary in such patients. Magnetic resonance imaging (MRI) with lateral views in flexion and extension seem to be the best method for detecting impingement of the spine on the cord.

[Basedow's disease in an adolescent with histiocytosis X]. / Maladie de Basedow chez un adolescent porteur d'une histiocytose X.

BACKGROUND: Immunological dysfunction is known to be present in Langerhans cell histiocytosis; some autoimmune diseases with autoantibodies associated with this condition have already been described. This immunological dysfunction could play a role in the Langerhans cell histiocytosis pathogenesis. CASE REPORT: A 13 year-old boy presented a multifocal bone Langerhans cell histiocytosis associated with Graves' syndrome. This last condition was successfully treated with carbimazole while the focal lesions of histiocytosis did not require any treatment. CONCLUSION: This unique association could be explained by the immunological dysfunction seen in Langerhans cell histiocytosis with secondary appearance of thyreo-stimulating antibodies.

[Congenital posterior bowing of the leg. 18 cases in children]. / Les courbures congénitales de jambe à concavité antérieure. 18 observations chez l'enfant.

The authors have seen 18 cases of congenital posterior bowing of the tibia and fibula associated with valgus deformity and shortening. They have noted that the valgus deformity had a tendency to improve during the first four to five years of life. The recurvatum may also improve, but less so than the valgus. Walking is not frequently impaired significantly by the deformity. When it is, an early osteotomy should be done, associated with lengthening using a Wagner distractor. In most of the cases, the progress of the case cannot be predicted accurately. It is therefore concluded that surgical correction-epiphysiodesis in three cases or progressive lengthening in five cases should be performed as late as possible.

[Congenital asymmetrical pelvis. Clinical, radiological study and outcome]. / Le bassin asymétrique congénital. Etude clinique, radiologique et évolution.

In congenital pelvic obliquity, there is a restricted abduction in one hip and an abduction contracture in the other. This association has been considered as a cause of acetabular dysplasia with progressive subluxation of the hip opposite to the abduction contracture. The clinical and radiological study of 120 children with an average follow-up of 3 years and 3 months permitted to demonstrate that two different types exist: the simple types (93 cases) without dysplasia, which never developed progressive subluxation and must not be treated, and the pelvic obliquities with dysplasia-subluxation-dislocation (27 cases) which have to be treated if the decentration of the hip opposite to the abduction contracture is marked. Distinguishing between these two types may be difficult because the X-ray is nearly never strictly correct because of the pelvic obliquity. This work leads to a better comprehension of the acetabular dysplasias who are subdivided into pseudodysplasias, secondary dysplasias and primary dysplasias. In the screening for the detection of congenital dislocation of the hip, it is essential that a pelvic obliquity be recognised because it constitutes a sign of hip at risk. Then, the clinical research of instability could be completed by echographic study in the two or three months or by radiographic study after 3 months in order to have a very precise diagnosis and apply the best treatment.

[Old post-traumatic dislocation of the radial head in children]. / Luxations anciennes post-traumatiques de la tête radiale chez l'enfant.

27 cases of neglected post-traumatic dislocations of the radius head were followed up for 30 years. 23 of the cases were neglected Monteggia fractures. The treatment varied over the years from no therapy to the presently used technique of cubital osteotomy associated with surgical repositioning to the radius dislocation. The follow-up results were analysed to determine: 1) whether surgical intervention was justified, as the function of the upper limb of these children was often perfectly good, 2) the type of surgery to use, 3) when such surgery should be done. The results form this study, and the review of 66 previously published cases indicate that surgery may be done on patients of any age, but preferably as early as possible, using precise surgical procedure, as these alone seem to guarantee a first class functional outcome, likely to improve on the pre-operative status of the patients.

[External fixation in fractures of the lower limb in children]. / La fixation externe dans les fractures du membre inférieur de l'enfant.

PURPOSE OF THE STUDY: The indications, morbidity and results of the use of external fixation for fractures of the lower limbs in children is presented. MATERIAL AND METHOD: We studied 72 fractures of the lower limbs (femur: 25; tibia: 47) in 63 children over a seventeen year period. Average age at fracture was 10 yrs 6 mos. (range 4 yrs 5 mos to 14 yrs 6 mos). Forty fractures were open fractures. The indication for external fixation was decided in three different situations: 39 isolated fractures, 11 patients with multiple fractures, and 13 polytraumatized patients. Three different devices were used: Illizarov: 4, Judet: 16, Orthofix: 52. The fixators were left in place until fracture union was demonstrable. RESULTS: Final results were classed into three groups: good, good following reoperation and sequelae. Comparison of the three different series was made using Student's T test. 9 axial deviations or malrotations occurred: 6 times correction was possible with the device in place. Three cases of osteomyelitis occurred at the fracture site. 23 pin tract infections occurred (23 per cent) 5 of which were persistent and 4 required reoperation. The average healing time was different in the three groups: 4.5 mos for isolated fractures: 8.1 mos for multiple fractures and 5.7 mos for polytraumatized patients. Reoperation was required for 4 patients: 2 bone grafts, 1 decortication, 1 bone transport. Ten refractures occurred following removal of the device, 8 times in patients presenting multiple injuries. In 46 patients with a follow-up greater than 18 months, 9 presented an overgrowth between 1 and 2 cm. Following an average follow-up of 2 years 4 months, 7 patients presented sequelae, 56 had good results, 18 following reoperation. DISCUSSION: The use of external fixation remains an irreplaceable method for osteosynthesis of open fractures with severe soft tissue injuries, multiple fractures or in the polytraumatized patient. Some disadvantages such as pin tract infections and refracture following device removal should be taken into consideration before using it for the treatment of simple, isolated closed fractures of the lower limbs in children. CONCLUSION: When external fixation is chosen for treating fractures, it is preferable to use a modular device which allows axial corrections. Local pin site care is essential to prevent early infection. Early weight bearing and dynamization as soon as possible will promote callus mineralization, removal of the device must be progressive and cast protection is recommended.

[MacFarland fractures. A series of 24 cases]. / Fractures de Mac-Farland. Etude d'une série de 24 cas.

PURPOSE OF THE STUDY: MacFarland fracture is a joint fracture of the ankle in children. The fracture line passes through the medial part of the lower epiphyseal disk of the tibia. Prognosis is dominated by later risk of malalignment and osteoarthritis. MacFarland fracture usually occurs subsequent to adduction trauma. The aim of this study was to analyze prognosis in a retrospective series of children with MacFarland fractures. MATERIAL AND METHOD: The series included 24 cases (14 boys and 10 girls, mean age at the time of trauma 12.7 years, age range 10-15 years). The fractures were classed into two groups according to the Salter and Harris classification for epiphyseal detachment: Salter 3 (n=4) and Salter 4 (n=20). Surgical treatment was given in 17 cases (11 screw fixations, 4 pin fixations and 2 other ostheosynthesis combinations). Orthopedic care was given in 7 cases (mean immobilization=40 days). All 24 children were followed for a mean 3 years 2 months (3 months=12 years). Three outcome categories were used: good (no pain, stiffness or malalignment), fair (pain and/or stiffness, no malalignment), and poor (malalignment). RESULTS: Overall results were good in 15 cases, fair in 2 and poor in 7 (29 p. 100). Ankle malalignments (7 cases) required surgical correction: epiphysiodesis for varus<5, supramalleolar tibial valgization osteotomy for varus > 5 degrees. After these procedures, outcome was good with a normally aligned painless ankle at 13 months follow-up. Among factors predictive of malalignment (poor outcome), power of the initial trauma (traffic or sports accident in 5 of the 7 poor outcomes), crush injury (medial metaphyseal comminution in two cases which led to varus ankle despite well conducted treatment), fracture type (7 malalignments among the Salter 4 fractures versus none among the Salter 3 fractures), initially defective reduction or osteosynthesis material passing through the epiphyseal disk leading to epiphysiodesis. DISCUSSION: Careful radiologic and clinical surveillance is needed and should be continued to the end of growth (fusion of the tibial cartilage) in children with high risk fractures in order to detect epiphysiodesis early and avoid secondary malalignment. Surgical correction does remain possible and gives good results.

[Upper metaphyseal lengthening of the tibia. Report of 57 cases in children and adolescents]. / Allongement métaphysaire supérieur du tibia. 57 cas effectués par la méthode du callotasis chez l'enfant et l'adolescent.

INTRODUCTION: The authors reviewed 57 upper metaphyseal lengthenings of the tibia. They especially studied complications in order to evaluate this method. MATERIAL AND METHODS: Fifty seven tibial lengthenings in 47 children and adolescents were reviewed. All lengthenings were performed according to the callotasis technique, using Judet's lengthener in the first 15 cases, the, OF-Garches Orthofix in 42 cases. All the callotasis principles were applied: delayed elongation, 1 mm per day distraction, one month neutralization after elongation period, then dynamization before removing the apparatus. Particularities were: a) metaphyseal osteotomy of the upper tibia, b) screw fixation and osteotomy of the fibula, c) classical dynamization according to De Bastiani and Aldegheri in 29 cases, dynamization by a silastic collar (OF-Dyna-Ring) in 28 cases. METHODS: Severity of complications was classified according to Caton: none, benign, serious (needed reoperation or reanesthesia) and severe (sequel). Complications and rate of lengthenings without complication or with benign complications were studied relative to etiology, age, amount of lengthening and the stage of program in which they occurred. A table summarizes data of all the lengthenings. RESULTS: Lengthening was 52.3 mm in average. Healing time (number of days to lengthen and to fuse the bone divided by the number of lengthened centimeter) was 40 in average (range: 20-105): it was 45.6 days per cm when using classical dynamization and only 34.3 with silastic collar dynamization (p = 0.002). Total of complications was 59 out of 57 lengthenings. 21 complications were benign, 37 serious and 1 severe (partial motor palsy of the foot). Thirty two (56 per cent) lengthenings were performed without unforeseen procedure or anesthesia. There were 4 intra-operative complications: 1 vascular lesion, 1 incomplete osteotomy and 2 malpositioned half screws. Complications of elongation period were the most numerous, 4 transient palsies, 6 knee contractures (2 led to a supracondylar fracture), 6 equinism (4 needed an Achilles tendon lengthening), 12 valgus deviations in which 9 were realigned using OF-Garches fixator without reoperation, 1 serious depression occurred in a bilateral lengthening. Consolidation was achieved without complication in 52 cases. Complications were: 1 refracture (fourth lengthening of the same tibia), 1 delayed union, 1 non-union, 2 late deviations. DISCUSSION: Rate of nervous and joint complications is close to that of other series. However, a high osteotomy decreases the consequences on the foot without increasing knee contracture in flexion. The ability to realign during the elongation period appears to be a prevention of valgus deformity compared to Wagner's technique. The authors's distractor is better tolerated than Ilizarov's. Problems with consolidation are rare, less than 9 per cent of the cases. CONCLUSION: A modular distractor improves the results of tibial lengthening; realignment is possible before, during or after the elongation. OF-Orthofix is easy to apply and well-tolerated by the patient, especially in bilateral lengthenings. Performing a high osteotomy, the callus is thick and the consolidation is quickly achieved and safe. A well-thought dynamization using Orthofix Dyna-Ring decreases the treatment time which is 35 days per centimeter in average.

[Synostosis and tarsal coalitions in children. A study of 68 cases in 47 patients]. / Synostoses et coalitions tarsiennes chez l'enfant. Etude de 68 cas chez 47 patients.

INTRODUCTION: The authors report their experience with tarsal coalitions in children. The purpose of this study was to discuss the origins of the << too long anterior process >> of the calcaneum, and to propose a simple therapeutic strategy for diagnosis and treatment. MATERIALS AND METHODS: The study included 47 children (68 feet), with one or more idiopathic tarsal coalitions. All patients had physical examinations to record symptoms, morphology of the foot, mobility of the foot, gait analysis, standard radiographs, and in some cases CT scans or MRI. The average age of the patients was 11.5 years old, 7 patients had a positive family history for tarsal coalitions. 66 per cent of the patients had mild tarsal pain or a history of repeated ankle sprains. The conservative treatment concerned 28 feet: 3 casts, 2 injections of corticosteroids into the subtalar joint, insole-shoes in 3 cases, and abstention in 20 cases. The operative treatment (40 feet) consisted of resection of calcaneonavicular coalitions (24 feet) resection of talocalcaneal coalitions (3 feet), mediotarsal and subtalar arthrodesis (8 feet), resection of calcaneonavicular coalition combined with the ""Cavalier'' procedure described by Judet (3 feet), calcaneal osteotomy (2 feet). RESULTS: The mean follow-up was 42 months. The morphology of the involved foot was normal in 33 cases, flat foot was seen in 24 cases (4 peroneal spastic flat feet), pes cavus in 3 cases, club foot in 2 cases, pes varus in 4 cases, ""Z'' shaped feet in 2 cases. The radiological examination was demonstrative of tarsal coalition in 61 feet. 7 tarsal coalitions were seen during operative procedures. The location or the coalition was calcaneonavicular (57), talocalcaneal (16), talo-navicular (8), calcaneo-cuboid (7), naviculo-cuneiform (4). The secondary radiographic signs were studied for each foot. In the conservative group, 2 patients degraded their clinical status, one developed a spastic flat foot. In the surgical group, all except 2 patients had good clinical and functional results. One patient had persistent pain in the subtalar joint after a technically correct calcaneonavicular resection. One patient had recurrent spastic flat foot following isolated talocalcaneal resection in a foot presenting multiple tarsal coalitions. This patient was reoperated by a mediotarsal and subtalar arthrodesis with a good result. DISCUSSION: The authors believe that tarsal coalitions have to be recognized based on a history of repeated ankle sprains or subtalar pain. Pain radiographs are diagnostic in most cases. CT scans and MRI are useful when radiographs are negative, especially in young children, or for talocalcaneal coalitions. The authors believe that the ""the too long anterior process'' of the calcaneum in calcaneonavicular coalition has the same embryologic origin. Operative treatment is suitable, when tarsal coalitions are symptomatic or after failure of conservative treatment. Resection gives good results with calcaneonavicular coalitions and selected talocalcaneal coalitions. The mediotarsal and subtalar arthrodesis is suitable in spastic flat foot, or when the bony-bridge is too big, or when the involved joint presents degenerative changes in these cases, the MRI is very useful to select patient for resection or for arthrodesis. CONCLUSION: Evocative history and plain radiographs are diagnostic of most tarsal-coalitions. Modern imagery is useful for difficult diagnostics, for young children, or for evaluation of a joint before resection or arthrodesis. Resection is a good treatment for calcaneonavicular coalitions and gives good results for talocalcaneal coalitions in selected patients.

[Femoral lengthening by callotasis. A study of a series of 79 cases in children and adolescents]. / Alongement de fémur par callotasis. Etude d'une série de 79 cas chez l'enfant et l'adolescent.

PURPOSE OF THE STUDY: Results of femoral lengthening using callotasis method, with particular attention to the complications are presented. MATERIAL AND METHODS: 79 femoral lengthenings performed for limb length discrepancy in 75 children and adolescents were studied. Etiology of the femoral shortening was congenital in 23 cases, post-traumatic in 20, post-infection in 14, neurologic in 13, and miscellaneous in 9. Nine lengthenings were performed using the Judet lengthener and 70 using the Orthofix external fixator. We used gradual incremental distraction (callotasis). RESULTS: Average lengthening achieved was 52 mm (range: 35 to 85), which represented a 17.7 per cent increase in femoral length (range 7.6 per cent to 64 per cent). There were 87 complications, i.e. 110 per cent. Several complications were often encountered during one lengthening, thus, 23 lengthenings (30 per cent) were performed without any complication and 49 (62 per cent) without additional unpredicted operations or anesthesia. All these complications were studied according to the stage (intraoperative, elongation, consolidation and delayed) in which they occurred and to their severity. They were assessed to establish their relationship to etiology of shortening, amount of lengthening and age. Intraoperative complications were rare (2 cases). In the distraction period, joint complications are the most frequent (33 complications), involving the hip 22 times and the knee 11 times; 28 healed without any problems, 14 needed reoperation and 1 dislocation of the hip led to an avascular necrosis. DISCUSSION: The incidence of joint complications did not seem to be less than that encountered with previous methods of lengthening. The author believes that systematic tenotomies performed in order to avoid such complications in congenital short femurs are abusive and have to be discussed case-by-case. Bony consolidation was achieved without additional surgery in 90 per cent of cases. Eight patients had delayed consolidation but did not require surgery. Complicated consolidation was most commonly encountered in children less than 8 years old with congenitally short femurs. The author compared healing time according to the type of dynamization. A significant improvement was found when using a silastic collar (33.3 days/cm) in place of classical dynamization (46.6 days/cm). CONCLUSION: The author believes that good results can be obtained by incremental distraction using uniplanar fixation. Results could be improved by proper fixator application, aggressive physical therapy and well-thought dynamization of the fixator.

[Long-term results of surgical treatment of congenital elevation of the scapula]. / Résultats à long terme du traitement chirurgical des surélévations congénitales de l'omoplate chez l'enfant.

This study reviews the cases of 21 children with 24 Sprengel's disease, operated from 1961 to 1981. They were classified according to the classification of P. Rigault and J.C. Pouliquen (5 grade I, 12 grade II, 4 grade III). Multiple deformities were associated. The average operative age was 8 years old. The surgical procedure was in 3 cases a partial scapular resection; in 15 a unilateral Woodward and in 3 a bilateral Woodward. The authors have observed 7 post-operative complications, including 2 brachial plexus palsies. The average follow-up is 12 years. Cosmetic results are good in 57.2 per cent, fair in 33.3 per cent and poor in 9.5 per cent. The study of function shows 18 normal shoulders with an average improvement of 51 degrees. Partial resection results seem to be good on mobility and fair on the cosmetic stand point. On the other hand, the results of Woodward procedure are distinctly better. Good results appear to be grade I, operated with Woodward technique and a resection of the most prominent part of the scapula. The authors propose their indications, knowing that Woodward procedure does not solve every problem, and that the existence of associated deformities may go against any surgical correction.