Legg-Calvé-Perthes disease.

Current knowledge of the causes and risk factors of Legg-Calvé-Perthesdisease (LCPD) does not allow effective preventive strategies. The outcome in adulthood is usually good. Hip osteoarthritis rarely develops before 50 years of age. The risk of osteoarthrosis depends chiefly on the final degree of joint incongruence. Age at onset and the lateral pillar classification are the two main outcome predictors and serve to guide the surgical indications based on the studies by Herring's group. Non-operative treatment is not effective. In contrast, femoral varus osteotomy and Salter's innominate osteotomy provide good outcomes. In severe forms, however, combining these two techniques or performing a triple pelvic osteotomy seem preferable. Surgery is now performed considerably less often than in the past, as it is effective only in patients with lateral pillar group B or B/C disease with onset after eight years of age. In other situations, therapeutic abstention is recommended.

[Can iatrogenic air embolism related to intraoperative use of hydrogen peroxide be easily avoided?]. / Embolie gazeuse iatrogène due à l'utilisation peropératoire d'eau oxygénée: un accident facilement évitable?

Air embolism is a rare complication of intraoperative use of hydrogen peroxide. We present the case of a young girl who underwent surgery for septic nonunion of the femur and developed this complication postoperatively. Outcome was fortunately favorable. A review of the surgery and anesthesia literature revealed the pathogenic mechanism of this type of accident together with the appropriate diagnostic and therapeutic practices. We propose here a series of preventive measures based on our experience and data in the literature: inform the anesthetist before using hydrogen peroxide, use a cup instead of a syringe for administrating hydrogen peroxide and avoid use in deep highly vascularized cavities.

Secondary localisation of an intra-thoracic benign mesenchymoma in the fossa poplitea: a rare paediatric case.

Thymomas are tumours that rarely occur in children, are almost invariably benign, and are usually discovered incidentally in the anterior mediastinum on chest X-rays. Whereas in adults these tumours are often associated with myasthenia gravis and other autoimmune diseases, this occurrence is very rare in the paediatric population. Multiple localisation and/or extra-thoracic recurrence of thymomas in children also appears to be exceptional with no reported cases in the English literature. We report one rare paediatric case.

Surgical treatment using The Unit Rod in children with neuromuscular scoliosis.

The article represents a retrospective clinical and radiological study. Objective. To assess the safety and the stability in time of the Unit Rod instrumentation in the treatment of severe neuromuscular scoliosis in children and adolescents. Summary. The treatment of patients with neuromuscular scoliosis always represents a challenge. The patients are debilitated and usual interventions are very long with great loss of blood. Serious complications can compromise the result of the surgery. The technique we used (the Unit Rod) is worldwide recognized, is simple, and gives excellent stability with a low rate of complications. Methods. We conducted a clinical and radiological retrospective study with a follow-up of at least 4 years in 58 patients with serious neuromuscular conditions, most of them being non-walkers. They were surgically treated by using mostly the Unit Rod technique, in the department of Paediatric Orthopaedics of the Rouen University Hospital, France, between 2000 and 2008. The back fusion was generally from T2 to pelvis. We used the Galveston technique for the patients who needed a pelvic fixation. Results. The mean Cobb angle correction was of 67% immediately after surgery; the correction of the curve decreased in time only in 4% of the cases. Pelvic obliquity was also very well corrected: 73% immediately and 70% at the last radiological follow-up. The mean operative time was of 175 minutes compared to 269 minutes for screws and hooks instrumentation. The most common complication for our technique was the radiolucent halo that appeared around the pelvic inserts. There was no significant degradation in time of the correction obtained. Conclusions. The use of this technique is safe, gives excellent results, achieving significant improvements in the postoperative functional status of the patients. The intra- and postoperative complications were minor. The advantage of using this method is the low cost of the material and technical simplicity, the corrective results being the same as the ones obtained with other techniques.

[The script concordance test: a new evaluation method of both clinical reasoning and skills in internal medicine]. / Le test de concordance de script: un nouvel outil d'évaluation du raisonnement et de la compétence clinique en médecine interne ?

OBJECTIVE: The script concordance test is designed to evaluate knowledge organization, which constitutes a crucial parameter of clinical skills. The objective of the present study was to assess the value of a new written evaluation tool to measure clinical skills in Internal Medicine. MATERIALS AND METHODS: A 95-item examination was completed by a group of medical students (N =17), a group of residents in Family practice (N =9), a group of residents in Internal Medicine (N =5), and a group of experienced physicians in Internal Medicine (N =7). The scores obtained were compared by analysis of variance. The reliability of the test was studied by calculating Cronbach's coefficient alpha. RESULTS: The mean score was 220.3 +/-41.7 for medical students, 230.5 +/-31.7 for residents in Family practice, 274.2 +/-32.2 for residents in Internal Medicine, and 352.1 +/-22.9 for experienced physicians in Internal Medicine. The differences observed between the scores for the various groups were significant (P <0.0001). Moreover, the value of Cronbach's coefficient alpha was 0.81 in the whole examination. CONCLUSION: Our data indicate that the script concordance test may easily allow to differentiate various levels of clinical skills in Internal Medicine. Moreover, because of Cronbach's coefficient alpha as high as 0.81, our findings suggest the validity of this test in Internal Medicine.

[Fishtail deformity after a non-displaced supracondylar humeral fracture in childhood: A case report]. / Hypoplasie de la joue latérale de la trochlée à distance d'une fracture supracondylienne de l'humérus non déplacée chez l'enfant : à propos d'un cas.

We report the case of a 13-year-old boy presenting with stiffness and pain in the elbow, which had appeared a few years before consultation. He reported a history of a closed, nondisplaced supracondylar fracture of the humerus 7 years before. Progression was good after orthopedic treatment. X-rays and CT showed a distinctive deformation, called a fishtail deformity, associated with severe arthritic injuries. We recall here that supracondylar fractures of the humerus are common in children and that early reduction decreases the complication rate. However, this case shows that fishtail deformity is a late and serious complication, which may occur after a nondisplaced supracondylar fracture of the humerus, with no severity factors and with good early progression.

Evolution of adolescent idiopathic scoliosis: results of a multicenter study at 20 years' follow-up.

INTRODUCTION: To date there is no consensus on therapeutic indications in adolescent idiopathic scoliosis (AIS) with curvature between 30° and 60° at the end of growth. OBJECTIVE: The objective of this study was to assess outcome in patients with moderate AIS. MATERIAL AND METHODS: A multicenter retrospective study was conducted. Inclusion criteria were: Cobb angle, 30-60° at end of growth; and follow-up > 20 years. The data collected were angular values in adolescence and at last follow-up, and quality of life scores at follow-up. RESULTS: A total of 258 patients were enrolled: 100 operated on in adolescence, 116 never operated on, and 42 operated on in adulthood. Mean follow-up was 27.8 years. Cobb angle progression significantly differed between the 3 groups: 3.2° versus 8.8° versus 23.6°, respectively; P < 0.001. In lumbar scoliosis, the risk of progression to ≥ 20° was significantly higher for initial Cobb angle > 35° (OR=4.278, P=0.002). There were no significant differences in quality of life scores. DISCUSSION: Patients operated on in adolescence showed little radiological progression, demonstrating the efficacy of surgical treatment for curvature greater than 50°. Curvature greater than 40° was progressive and may require surgery in adulthood. Lumbar scoliosis showed greater potential progression than thoracic scoliosis in adulthood, requiring fusion as of 35° angulation. LEVEL OF EVIDENCE: IV, retrospective study.

Posterior arch bifocal fracture of the atlas vertebra: a variant of Jefferson fracture.

Fracture of the atlas vertebra is rare in children. We report two paediatric cases of bifocal pedicular fracture of the posterior arch of C1. Evaluation was performed by nonenhanced computed tomography scan, which successively confirmed both diagnosis and healing. In both cases, nonoperative management was successful.

[Has the Ilizarov technique come of age in pediatric orthopedics?]. / L'âge de raison du matériel d'Ilizarov en orthopédie pédiatrique?

The Ilizarov method can be used for several applications: limb lengthening correction of axial malignement, pseudarthrosis, traumatology and in several sites: leg, foot, knee, femur, forearm and arm. The authors recall the principles and possibilities of this method and give details about its utilisation for each indication, and for their preferred indications: lengthening for marked disparity, complex trauma, progressive distraction of soft tissues, and for very young children.

[The exam request seen by the radiologist, the report seen by the clinician]. / La demande d'examen vue par le radiologue, le compte-rendu vu par le clinicien.

PURPOSE: To analyze the impact of radiology requests and reports on the quality of the radiology consultation. METHOD: Over a 6 month period, the authors have collected radiology requests and reports deemed incorrect. These documents have been classified. A review of the literature has been conducted, then an attempt has been made to summarize the main elements to be included in radiology requests and reports to improve quality. RESULTS: Twelve categories of improper requests and 8 categories of improper reports have been identified. CONCLUSION: Requests and reports represent two essential steps of the consultation process in radiology. These two aspects are not sufficiently emphasized at medical school and during residency training in France. The efficiency of both steps mainly depends on the interaction between the referring physician and the radiology consultant.

[Focal dermal hypoplasia: description of three cases]. / Le syndrome de Goltz: à propos de trois observations.

BACKGROUND: Focal dermal hypoplasia syndrome is mainly defined by the association of abnormalities of extremities, atrophy and linear hyperpigmentation of the skin, localized deposits of superficial fat, anomalies of the eyes and of the nails. Neonates are often small for their age. CASE REPORTS: Three sporadic cases are reported. Mental delay and omphalocele were observed in the first case. The neurological development was subnormal in the second and an unusual monodactyly was seen in the third. CONCLUSION: Most cases are sporadic, but in family cases, an X-linked dominant factor is likely. When a first affected offspring is observed, skin examination and X-ray should be carried out in parents to evaluate the risk of recurrence in their children. As the gene site has not yet been determined, antenatal diagnosis should be suspected on echography when fetal growth delay is associated to distal limb and/or ocular anomalies.

[Kingella kingae osteoarticular infections in children. A report of a series of eight new cases]. / Les infections ostéoarticulaires à Kingella kingae chez l'enfant. A propos d'une série récente de huit cas.

UNLABELLED: Kingella kingae is a Gram-negative bacillus which belongs to the Neisseriaceae family. Its involvement in osteoarticular infections is relatively recent. METHODS AND RESULTS: We report eight cases of Kingella kingae osteoarticular infections that have been diagnosed at the paediatric surgical centre of Rouen University Hospital since October 1995. Six boys and two girls (mean age: 30.6 months) presented with osteomyelitis in six cases and arthritis in two. Only 75% of patients had a fever at time of diagnosis. The biological findings were slightly modified. All samples were obtained from blood, bone or joint fluid. These samples were systematically inoculated into a blood culture tube. Positive Kingella kingae culture was achieved in seven local samples and in one blood culture. All children received two antibiotics via intravenous injection while waiting for the bacteriologic results. Later, the antibiotic treatment (amoxycillin) was given per os. The mean duration of treatment was 33 days. Patients were given intravenous treatment for a period of only ten days. Six patients were followed up for a period of more than 18 months and outcome was always uneventful. DISCUSSION: Kingella kingae is usually present in the nasopharyngeal mucosa and spreads in the blood due to various infections. Different types of Kingella kingae infection have been reported with a large frequency of osteoarticular infection. CONCLUSION: This type of infection does not present any unusual characteristics as compared to other osteoarticular infections. Because of its antibiotic sensitivity treatment duration could be reduced. Kingella kingae is a fragile microbe and its culture is often difficult; therefore, it is important to use blood culture tubes to inoculate joint fluid and bone samples.

[Hip dislocation. Organization of screening and follow-up]. / La maladie luxante de hanche. Organisation du dépistage et de la prise en charge.

Early detection and low-risk treatment are the two main objectives of the management of developmental dislocation of the hip. The best way to evaluate neonatal hips is to perform clinical and ultrasound examinations at the same time, and to confront their results. Early diagnosis allows to restrict treatment to infants with neonatal dislocation who do not improve by 4 weeks of age. On the other hand, neonates with reductible dislocated hips must be treated at birth and followed at the joint consultation. Early diagnosis and management must not decrease later efforts to detect dislocated hip until walking age.

[Amniotic band syndrome: pathogenesis, prenatal diagnosis and neonatal management]. / Maladie des brides amniotiques: étiopathogénie, diagnostic anténatal et prise en charge néonatale.

Amniotic band syndrome is a collection of fetal congenital malformations, affecting mainly the limbs, but also the craniofacial area and internal organs. Two mains pathogenic mechanisms are proposed: early amnion rupture (exogenous theory) leading to fibrous bands, which entrap the fetal body; the endogenous theory privileges vascular compromise, mesoblastic strings not being a causal agent. The outcome of the disease depends on the gravity of the malformation. Termination of the pregnancy is usually proposed at the time of the diagnostic of severe craniofacial and visceral abnormalities, whereas minor limb defects can be repaired with postnatal surgery. In case of an isolated amniotic band with a constricted limb, in utero lysis of the band can be considered to avoid a natural amputation. However, as the exact etiology of amniotic band syndrome remains unknown and its natural course unpredictable, prenatal surgery continues to be controversial. Doppler studies of the constricted limb could be of useful predictive value of in utero amputation, and therefore could be helpful to determine when in utero treatment should be considered.

[Evaluation of clinical competence in gynecology obstetrics: an innovative approach using the Objective Structured Clinical Examination]. / Evaluation au cours de la formation initiale de la compétence clinique en Gynécologie Obstétrique: approche innovatrice basée sur l'observation de la performance par l'examen clinique objectif et structuré (ECOS).

OBJECTIVE: The evaluation of medical student clinical competence in Obstetrics and Gynaecology using Objective Structured Clinical Examination (OSCE). MATERIAL AND METHODS: Development of OSCE with definition of an assessment of subject, choice of clinical stations sampling, identification of components of clinical competence to be evaluated, the level of performance required, development of specification table, editing of OSCE presentation page and assessment of praticability and results exploitation. RESULTS: Eleven station stimuli with simulated patient participation were carried out, 2 stations with a mannequin model and 1 questionnaire station. CONCLUSION: Our experience suggests OSCE feasibility for Obstetrics and Gynaecology during the initial course of education presents adequate psychometric characteristics. This gold standard can no longer be overlooked and should be considered as a useful tool to assess medical student competence. Nevertheless, OSCE remains to be further evaluated in France.

[Post-traumatic epiphysiodesis of the distal end of the tibia in children]. / Epiphysiodèses post-traumatiques de l'extrémité inférieure du tibia de l'enfant.

PURPOSE OF THE STUDY: Thirteen distal traumatic epiphyseal closures of the lower end of the tibia are studied. A bony bridge resection was performed in nine cases. The aim of this study was to define the kind of injury that drives to epiphysiodesis in this localisation, and secondly to define the factors that may influence the results of de-epiphysiodesis. MATERIALS AND METHODS: One hundred and eighty-eight children were hospitalized between 1981 and 1995 for the treatment of a fracture of the lower end of the tibia. Six epiphysiodesis followed a Mac Farland lesion. Six epiphysiodesis followed a Salter and Harris Type-II injury. One epiphysiodesis followed a triplane fracture. The diagnostic of epiphysiodesis was performed at an average of 12 months after injury. The bony bridge interested less than 50 per cent of the growth plate in all cases. There was a varus deformation between 7 degrees and 20 degrees in six cases (average 13.8 per cent). Ten surgical procedures were performed: one fibular bi-focal epiphysiodesis and nine tibial de-epiphysiodesis including a resection of the bony bridge filled with acrylic cement. Two children were not operated because they were close to the end of growth and there was no varus deformation. One child was not reviewed. RESULTS: There was a significant correlation between the children age and the importance of the ankle varus deformation. The younger the children were and the more important the varus deformation was. Only three de-epiphysiodesis had a good clinical and radiological result. In five cases, a second surgical procedure was necessary. Fibular bi-focal epiphysiodesis gave a good clinical result. DISCUSSION: In this location, Harris and Salter type II fractures may have a poor prognosis for growth if the injury occurred with high energy. Varus deformation is a common way to discover epiphysiodesis in this location. There was no correlation between the children age and the result of the de-epiphysiodesis, and between the delay since injury and the de-epiphysiodesis result. There was a correlation between the result and the presence of a varus dexasation in the ankle. The more important the varus was and the poorer the result was. CONCLUSION: Mac Farland lesion and Salter and Harris type II lesion drive to epiphysiodesis more often than any other distal tibial fracture. Varus desaxation is more important in younger children and seems to determine de-epiphysiodesis results. But over all, de-epiphysiodesis has a poor prognosis in more than 60 per cent of cases.

[Osteochondral fractures of the external femoral condyle after traumatic patellar dislocation during physical exercise in children]. / Fractures ostéochondrales du condyle fémoral externe après luxation traumatique de la rotule de l'enfant sportif.

PURPOSE OF THE STUDY: Nineteen osteochondral fractures of the lateral femoral condyle associated with acute traumatic patellar dislocation resulting from sport injury in children were studied. The purpose of this study was to specify clinical and radiological features. MATERIAL AND METHOD: This study was led with special care to injury circumstances, fracture visibility on X-rays, size and location of the fracture, treatment delay, presence of femoro-patellar dysplasia signs. Treatment results were evaluated on knee pain, bone consolidation and recurrent dislocation. RESULT: Thirteen boys and six girls aged 8 to 16 years (average 14 years) were included. The injury resulted from a rotatory-compression stress in 75 per cent cases. The patella was always in place at the time of examination. Thirteen fractures were diagnosed within 24 hours and 5 fractures were diagnosed within 1 week after injury. One fracture was not visible on X-rays and was diagnosed 6 weeks after injury. Only the lateral view showed the fracture in more than one case out of two. Seven patients whose fracture was less than 5 mm, or involving a non-weight-bearing portion, or diagnosed within more than ten days after injury, were treated by knee arthroscopy and removal of the osteochondral fragment. Twelve patients were treated by arthrotomy and excision (one case) or replacement of the osteochondral fragment (11 cases). The replaced fracture was fixed with biological glue ten times, and screwed once. The knee was immobilised in a cylinder cast and weight-bearing prohibited for six weeks. Bone consolidation was obtained in 9 cases out of 11, in an average of 8 weeks. Knee pain occurred 5 times. Recurrence of the dislocation occurred 3 times within 6 months. Eighty per cent of these children showed patello-femoral dysplasia. DISCUSSION: This fracture complicated 31.6 per cent of traumatic patellar dislocation resulting from sport injury in children which we observed during the last ten years. It may be overlooked if it is suspected and carefully looked for by radiographic examination including antero-posterior, lateral, oblique and true skyline views of the patella. The presence of fat in the hemarthrosis may help. Early surgery is recommended. Arthroscopy may be performed to evaluate fracture location and size. After ten days, host area begins to fill in and free fragment will not fit back well. Fragments less than 5 mm, or involving a non-weight-bearing portion, or diagnosed within more than ten days after injury, may be removed. CONCLUSION: Lateral femoral condyle osteochondral fractures are associated with nearly one third of traumatic patellar dislocation resulting from sport injury in children. A detailed radiographic examination can help diagnosis. Treatment depends on the delay after injury, the size and location of the fracture.

[The tibio-calcaneus external fixator in the treatment of fractures of the lower tibia]. / Le fixateur externe tibio-calcanéen dans le traitement des fractures du pilon tibial.

Twenty-seven patients with complex fractures of the lower end of the tibia were treated by an external Hoffman fixator between 1977 and 1981. Its use was inspired by the presence of skin lesions and by the anatomical type of fracture when it was felt that other methods of treatment would be ineffective or hazardous. In favour of the method was the absence of iatrogenic infection and anatomical results that were superior to those of conservative treatment. Against it, there was a longer time for union, with eight delayed unions and three non-unions and the fact that it was impossible to correct joint impaction which was present in 14 out of 28 cases.

[Osteoarticular infection in children: evaluation of a diagnostic and management protocol]. / Infections ostéo-articulaires de l'enfant: étude de deux séries consécutives et évaluation d'un protocole de diagnostic et de traitement.

PURPOSE OF THE STUDY: The purpose of this study was to evaluate a diagnostic and management protocol for osteoarticular infection in children which was developed at the Rouen University Hospital in 1993. We studied the technical aspects of the protocol allowing improved certain diagnosis and bacteriological documentation as well as the reduction in intravenous treatments and hospital stay. MATERIAL AND METHODS: Two successive series were compared. The first constituted from May 1984 to February 1992 was a retrospective series of 106 children with osteoarticular infections. The second series was prospective an included 104 children with osteoarticular infection treated after institution of the protocol (January 1995 to December 1998). All children were treated in the same unit. Files were reviewed at a minimum follow-up of 18 months following the end of treatment. We analyzed: clinical, biological, and radiological data at admission; elements of the bacteriological study and their contribution to identification of the causal agent; duration of intravenous antibiotic therapy; total duration of antibiotic therapy, and hospital stay; complications and sequelae. RESULTS: After institution of the protocol, we observed significant progress: certain diagnosis of acute osteomyelitis improved from 67% to 85% after institution of a more comprehensive diagnostic program; bacteriological identification improved from 37.5% to 72.2% for acute osteomyelitis and from 41.6% to 59.5% for septic arthritis, with a growing number of recognized cases of Kingella kingae infections causing acute osteomyelitis (n=2) or septic arthritis (n=4) due to technical progress in sampling and culturing. Mean duration of intravenous antibiotic therapy (15 days versus 9.95 days), mean duration of total antibiotic therapy (47.3 versus 33.8 d) as well as length of hospital stay (17.5 d versus 12.5 d) were significantly improved. The shorter antibiotic therapy did not led to any supplementary morbidity. CONCLUSIONS: A systematic bacteriological diagnostic protocol has enabled an improvement in treatment and hospitalization. The protocol has been further updated and simplified in light of these findings and observations of insufficiencies, taking into account recent data in the literature and epidemiological features of osteoarticular infection in children.

[Failure of primary management of developmental dislocation of the hip: 31 years experience in Normandy]. / Echecs de la prise en charge initiale de la maladie luxante de la hanche en Haute-Normandie: analyse sur une période de 31 années consécutives (1968-1998).

PURPOSE OF THE STUDY: Primary management of developmental dislocation of the hip involves a series of events (clinical screening and detection, choice and interpretation of imaging studies, indication and proper execution of treatment). Each event has an important effect on outcome and failure may result from inadequate attention to any one. We analyzed the causes of failure observed over 31 years experience in our region. MATERIAL AND METHODS: We analyzed the files of children hospitalized in the Rouen Infantile Surgery Department from 1968 to 1998 for management of congenital dislocation of the hip diagnosed late (> 3 months) or for revision after inappropriate treatment. We identified 353 files. This series was retrospective from 1968 to 1985 (283 cases) and prospective from 1986 to 1998 (70 cases). RESULTS: Up through 1981, failed detection of developmental dislocation of the hip was identified in 10 to 27 children per year (mean 21.5). Since 1982, this rate has varied from 1 to 10 (mean 6.5). The number of children treated before the age of one year was 10.5 per year up through 1981 then 4.5 per year after 1982. The number of children treated after the age of one year was 11 per year through 1981 then 2 per year after 1982. Since 1986, treatment was undertaken for failure of primary management in 57 children after clinical diagnosis, in 3 children after radiological and ultrasonographic diagnosis, and in 11 children during the course of treatment. Standard x-ray studies systematically obtained at four months corrected the diagnosis in 24 children. The diagnosis was corrected after repeating the examination in 14 children before the age of one year. Correct diagnosis was established after the age of one year in 18 children. DISCUSSION: Although our University Department was the only referral center for pediatric surgery in our region during this period, these figures cannot be compared with the annual birth rate in the region (24,000 births/year) because the number of infants managed in other centers is unknown. Nevertheless, organizing regular follow-up by a pediatric orthopedic surgeon of all infants screened positive in the maternity ward enabled a 70% reduction in the number of failures since 1982. Systematic clinical screening, repeated regularly during the first year of life, has reduced the mean age of diagnosis. Neither ultrasonography nor radiography has replaced physical examination. Care must also be taken to avoid over reliance on ultrasound findings which do not correspond to clinical findings. Amongst the children treated late, 14% had undergone an inappropriate treatment for dislocation correctly identified during the neonatal period. Referring all children screened positive to a pediatric orthopedic surgeon should help reduce this rate.