[The role of bone cement in orthopaedic surgery]. / Le rô1e du ciment en orthopédie.

Bone cement has a central role in orthopaedic surgery. It is used with success in total joint replacement since years. Newer techniques such as vertebroplasty and kyphoplasty have been used during the last years. This article describes the chemical and mechanical properties of bone cement and will describe particularly his use in total hip arthroplasty and vertebropasty and kyphoplasty.

Spontaneous rupture of the spleen in relation to a non-Hodgkin lymphoma.

A 35-year-old man was admitted for surgery with complaints of left upper abdominal quadrant pain, tachycardia and hypotension with no history of trauma. A splenomegaly had just been diagnosed one week before, during, the work up for asthenia. An immediate CT scan revealed an intraperitoneal haemorrhage with splenic rupture. During emergency laparotomy, a splenic rupture was found and a splenectomy was performed. Histopathology of the spleen confirmed the diagnosis of a non-Hodgkin lymphoma.

Does nephroblastomatosis influence the natural history and relapse rate in Wilms' tumour? A single centre experience over 11 years.

The presence of multifocal or diffuse nephrogenic rests (NRs) in one or both kidneys is termed nephroblastomatosis (Nbm). Nbm may be a predisposing factor for Wilms' tumour (WT). The aim of this retrospective study was to evaluate the impact of Nbm on the outcome of WT in children. We assessed the outcome of 81 children with Wilms tumours and practical implications of Nbm in the treatment and follow-up. All the pathology slides have been reviewed in 1997. 63 had WT without Nbm (group A) and 18 had WT associated with Nbm (group B). There was no statistical difference between the two groups according to the age at diagnosis and histology. Clinical abnormalities were more frequent in group B (33 versus 8%). There was no statistical difference between the percentage of stage IV in both groups, but bilaterality (stage V) was present only in the group B. Relapse was observed in 20/81 patients (25%): 11 (17%) in group A and 9 (50%) in group B. Mean delay of relapse was longer (25 months) in group B than in group A (10 months). For the whole population, with a median follow-up of 9 years, the event-free survival (EFS) and the overall survival (OS) probabilities were respectively 74%+/-10 and 83%+/-9 at 120 months. The difference in EFS between groups A (82+/-9%) and B (38%+/-29) was significant (P=0.004). The discovery of Nbm in the non-tumoral part of the kidney with WT can be an adverse factor and in particular favours the subsequent development of a new Wilms tumour. It justifies separate follow-up guidelines.

Monitoring of lumbosacral nerve roots during spinal instrumentation.

A technique is described for intraoperative, multimodality electrophysiologic monitoring of the spinal cord and lumbosacral nerve roots (cauda equina). Simultaneous monitoring with the techniques of electromyography, compound muscle action potentials, and somatosensory evoked potentials is found to provide highly useful information to the surgeon during lumbar spine instrumentations. Compound muscle action potential recordings are used to identify nerve roots in the lumbosacral region, especially when visual identification of the nerve is hindered by scarring or distortion of the anatomy. Electromyography continuously monitors nerve roots at risk by revealing neurotonic discharges when the nerve roots are irritated during surgical dissection or placement of the fixation device. The early warning provided by this technique enables the surgeon to avoid irreversible neurologic damage.

Is the appendix graft suitable for routine biliary surgery in children?

BACKGROUND/PURPOSE: The appendix graft (AG) is used widely for urinary tract replacement in children. Biliary tract replacement is less common. The purpose of this retrospective multicentric study was to evaluate the safety of appendix grafting for biliary reconstruction. METHODS: The files of 33 patients treated at 7 European pediatric centers were reviewed. Indications included choledochal cyst (CC) in 5 cases, biliary trauma (BT) in 1, and biliary atresia (BA) in 27. In CC and BT patients, the graft was inserted isoperistaltically between the proximal biliary duct and second duodenum. In all but one of the BA patients, the graft was placed antiperistaltically by patching its cecal end onto the porta hepatis. RESULTS: Postoperatively, all CC and BT patients initially became asymptomatic but developed laboratory evidence of anicteric cholestasis within 1 year. The most common manifestation was increased gamma-glutamyl-transpeptidase level (GGT), whereas histologic findings showed liver damage (mainly fibrosis). Reoperation has been carried out in 4 CC and 1 BT patients within a mean period of 19 months after appendix grafting. The graft procedure was converted to hepaticojejunostomy (HJ) in 4 and to choledocoduodenostomy in 1. Surgical exploration showed kinking in 1 patient and stenosis in 1. In the remaining 3 cases, there was no discernible cause of cholestasis, and appendix histology findings were normal. In all 5 reoperated patients, liver function findings returned to normal within 1 month. Reoperation is scheduled for the remaining CC patient who currently requires ursodesoxycholic medication to maintain normal liver function and presents histologic evidence of "de novo" sclerosing cholangitis. Results of appendix grafting also were poor in the 27 BA patients. Procedure-related perioperative complications occurred in 4 (15%) including 1 early death from graft necrosis. Another early death resulted from intestinal hemorrhage. Jaundice cleared in only 8 (28%). CONCLUSIONS: The findings of this study suggest that the AG is unsuitable for routine biliary repair in children. It should be used only as a salvage technique when conventional HJ repair is contraindicated. Because of the high risk of graft dysfunction, we recommend screening tests to detect biochemical or histologic cholestasis in any patient previously treated with appendix grafting.

Cleft larynx: management and one-stage surgical repair by anterior translaryngotracheal approach in two children.

Cleft larynx is a rare congenital anomaly which is now being reported with increasing frequency. It is characterized by a midline posterior defect. Two children underwent laryngeal cleft repair by an anterior translaryngeal approach. Tracheotomy was avoided and closure of the anterior laryngofissure was carried out over the nasotracheal tube. The patients were cared for in a pediatric intensive care unit until extubation. Extubation was performed on day 8. The older child had few functional problems and did well whereas the younger child did poorly. In this latter case, the initially successful surgical result was impaired by post-operative aspiration, due to numerous possible factors: gastroesophageal reflux secondarily controlled by Nissen fundoplication, disturbed swallowing as a result more of the cleft repair work than of the surgical approach, or else immaturity of the suction-swallowing reflex.

One-stage tracheal reconstruction of congenital tracheal stenosis.

Congenital tracheal stenosis (CTS) is a condition difficult to manage and associated with a high mortality rate. The principles of one-stage laryngotracheoplasty have been adapted to the surgical management of CTS. Three children underwent a one-stage anterior tracheoplasty with costal cartilage grafting and without cardiopulmonary bypass. Extubation was performed within 13 days. One child developed granulation tissue one month postoperatively, and this was removed endoscopically. The three children were free of respiratory obstruction signs during follow-up ranging from 8 months to 3 years. Postoperative endoscopies have shown growth of the grafted trachea.

Surgical treatment of diaphragmatic agenesis by transposition of a muscle flap: report on 15 cases.

Between 1987 and 1996 the transposition of a muscle flap using the anterolateral abdominal wall (the internal oblique and transversus abdominus muscle) has been used for the surgical treatment of fifteen cases of diaphragmatic agenesis. There are several advantages of this technique: a more accurate reconstruction of the diaphragmatic dome, a better adapted muscle flap, good tolerance and evolution as a result of the use of autologous material with thus less risk of recurrence and/or infection. The disadvantages are represented by the nine cases of abdominal herniation at the site of the muscle flap, three of which necessitated secondary surgical treatment. Nine children survived this treatment, six died following severe cardio-pulmonary complications associated with this malformation.

[IMesenteric and mesocolic cystic lymphangiomas. Diagnostic and therapeutic management]. / Les lymphangiomes kystiques du mésentère et du méso-côlon. Prise en charge diagnostique et thérapeutique.

STUDY AIM: Study of clinical, diagnostic and therapeutic aspects of mesenteric and mesocolic cystic lymphangiomas. MATERIAL AND METHODS: 15 cases were retrospectively analysed: 5 adults (mean age 36.8 years, range 26 to 46) and 10 children (mean age 23 months, range 0 to 5 years). Diagnosis was prenatal in 1 case. Symptoms were: abdominal pain (80%), fever (20%), abdominal mass (46%), occlusive syndrome (33%), chylous ascitis 1 case. Tumours were mesenteric (86%) or mesocolic (13%). RESULTS: Complete resection was performed in 11 cases (including 10 bowel resections), incomplete resections in 3 and doxycycline sclerotherapy once. Mean follow-up is 5 years. One recurrence occurred 6 years after complete resection and 1 tumour increased after incomplete resection. Patient treated by sclerotherapy was non symptomatic with a 3.5 years follow-up after last injection. CONCLUSION: Mesenteric and mesocolic cystic lymphangiomas are congenital benign tumours. Complete resection should be performed whenever possible. Intracystic sclerotherapy with doxycyclin is possible for unresectable lymphangiomas.

[Current aspects of cystic lymphangioma in the neck]. / Aspects actuels du lymphangiome kystique cervical.

Cystic hygroma of the neck (CHN) is the result of a defect in the embryonary development of the lymphatic system. In many cases foetal ultrasound allows an early diagnosis before birth, the prognosis being very different according to the gestational age at the time of detection. When discovered before 30 weeks of gestation it is almost always associated with chromosomal abnormality and/or polymalformation leading to spontaneous or therapeutic abortion. On the contrary when appearing after the 30th week of gestation, CHN is usually an isolated malformation as when discovered during infancy or childhood. Approximately 2/3 of these "late" CHN are present at birth; 90% are discovered before 2 years of age. A spontaneous regression occurs in about 15% of the cases. In 70% of cases the CHN is simple without extension to the oropharynx or mediastinum and its complete surgical resection is usually easy. Extension to the oropharynx is present in about 20% of the cases; there is a risk of neonatal respiratory distress and the treatment is difficult. Extension to the mediastinum is found in about 10% of the cases; respiratory distress is rare and a large surgical resection is necessary. Surgery is the primary treatment of CHN after a careful evaluation of the extension of the tumor by ultrasound, scanography or nuclear magnetic resonance, and oropharyngeal endoscopy. It allows a "macroscopically complete" resection in about 80% of the cases, but a recurrence is observed in approximately one every five cases. Following partial resection or important recurrence, treatment includes according to the cases; new attempt of surgical resection, sclerosing therapy, and laser therapy for the oropharyngeal forms.

[Pheochromocytoma: pediatric features]. / Le phéochromocytome: particularités pédiatriques.

Pheochromocytoma is a rare tumor in children which explains, together with its miscellaneous symptomatology, why the diagnosis may be delayed. The localization of the tumor(s) rests mainly on MIBG scintigraphy, and CT scan and/or magnetic resonance imaging. Thanks to a systematic preoperative treatment of hypertension and major progress in anesthesia, the operative mortality of pheochromocytomas in children is nowadays very low. Nevertheless two major problems remain: 1) the difficulty of diagnosing and treating the malignant forms, 2) the high frequency of recurrences, sometimes many years after the removal of the primary tumor. A regular long term supervision is therefore necessary after the surgical treatment.

[Cardiospasm in a thirteen and half year old girl (author's transl)]. / Mégaoesophage idiopathique chez une fille de 13 ans et demi.

From a case in a 13 and half year old girl, the cardiospasm diagnostic basis are pointed out. Though infrequent this disease can occur in children and infants. During initial stage, the dynamic radiographic signs are difficult to recognize. In a more advanced stage, radiographic signs are clear. Radiographic examinations are also necessary in evaluation of surgical results, mainly in looking for post-operative gastroesophageal regurgitation.

[Severe urinary tract and cutaneous lesions after umbilical cord artery puncture and direct injection of hypertonic sodium bicarbonate to the newborn in the delivery room. Report of three cases (author's transl)]. / Lésions urinaires et cutanées par ponction d'une artère du cordon ombilical et injection à la serinque de soluté bicarbonaté hypertonique chez le nouveau-né en salle d'accouchement. A propos de trois observations.

Three cases of necrotizing and calcifying lesions of low urinary tract, buttock and adjacent perineum are reported. These lesions have been induced by direct syringe injection into an umbilical artery of 42% sodium bicarbonate solution at the dose of 5 to 6 ml/kg of body weight. Radiographic examinations are very important to study the urinary tract lesions. These have been surgically controlled in two cases. The follow up ranges from 10 to 21 1/2 months. On the bladder initial necrotizing lesions are followed by calcification and parietal retraction. These bladder lesions induce a more or less important ureterohydronephrosis. To these constant lesions are variably associated urethral calcifications and stenosis, distal ureter calcifications. These lesions seem to be related to the sodium bicarbonate hyperosmolality, to the injection conditions, and to the local hemodynamic features.

[Injuries to the upper extremities in the newborn diagnosed at birth]. / Les traumatismes du membre supérieur du noveau-né constatés à la naissance

Injuries to the upper limb vary in type. The overall incidence, including the form which is revealed by paralysis, is 2.6 per 1,000 (30 cases in 13,342 deliveries). In 90 per cent of cases it followed a dystocic delivery. The prognosis for these lesions is favourable when the diagnosis is made early and the correct treatment is started in the first days of life. All the same, sequellae are not rare, being in the order of 10 per cent, and this pathological condition should not be considered as a benign one. The pathology of these lesions does not depend only on the second stage of labour, nor entirely on the choice between hysterotomy and vaginal delivery, but equally on the prevention of the birth of large children and on the treatment of maternal obesity, as well as on a better estimation of the size ofthe foetus in utero by the development of measurements of the bi-acromial diameter with the use of ultra-sonic techniques.

[Prenatal diagnosis of congenital diaphragmatic hernia: evaluation of the prognosis]. / Diagnostic prénatal de la hernie des coupoles diaphragmatiques: évaluation du pronostic.

OBJECTIVE: The aim of this study was to evaluate prognostic prenatal factors of congenital diaphragmatic hernia. MATERIAL AND METHODS: We designed a retrospective study of 34 patients with congenital diaphragmatic hernia. The infants were delivered at the Edouard Herriot Hospital between September 1, 1994 and June 30, 1998. We excluded cases of pregnancy termination. After eliminating 4 cases, we studied 30. The factors studied were: polyhydramnios, transverse abdominal diameter, hepatic and umbilical vein deviation, mediastinal deviation, intrathoracic location of the stomach. Prenatal karyotype and echocardiography were systematically obtained. RESULTS: Total perinatal mortality was 53% and was 48% in case of unique diaphragmatic hernia. Prognosis was poorer if the diaphragmatic hernia was associated with another malformation (perinatal mortality: 80%, 4/5 cases), or in case of preterm delivery (83%, 5/6 cases). Factors associated with poor prognosis were: polyhydramnios, transverse abdominal diameter below the 5(th) percentile and major hepatic deviation. Diagnosis before 25 weeks was not associated with poor prognosis. Intrathoracic stomach was a good diagnostic sign, but did not allow an assessment of prognosis. CONCLUSION: Diagnosis of congenital diaphragmatic hernia was made before 25 weeks in 77% of the cases. It was not a factor of poor prognosis. As other authors, we found that prenatal association with another malformation (especially cardiac malformation) polyhydramnios, deviation of the liver, and abdominal transverse diameter below the 5(th) percentile were factors of poor prognosis. But it was difficult to determine the prenatal prognosis. Improvement is needed.

[Desmoplastic tumors with multiple differentiation. A new entity. Six cases]. / Tumeurs desmoplastiques à différenciation multiple. Une nouvelle entité. Six observations.

Desmoplastic tumours with divergent differentiation are principally located in the abdomen and develop locally or regionally. They occur in adolescents or young adults and are characterized at histology by a proliferation of undifferentiated small cells surrounded by a dense stroma. Only immuno-histo-chemistry provides the diagnosis. Since their chemosensitivity is rare and often partial the outcome is usually lethal. Six new cases of this recently described entity are presented here. The authors are in favour of a multidisciplinary and aggressive management, combining intensive polychemotherapy, extensive surgical exerisis and total abdominal radiotherapy.

[Posttraumatic club-hand. Therapeutic problems (apropos of 5 cases)]. / Main bote post-traumatique. Problèmes thérapeutiques (à propos de 5 cas).

Progressive radial deviation after epiphyseal separation in children is a rare complication. It is related to an imbalance of residual growth potential of the lower ends of the radius and ulna together. The functional disability is generally moderate. 5 cases were observed by the authors, all of which were treated surgically. The mechanism of the deformity and the surgical techniques are described. These are lengthening of the radius, angulation osteotomy of the radius, shortening of the ulna or epiphysiodeses. In some cases, operative excision of a partial epiphyseal closure can be done provided that there has been a close follow up after the trauma and an early diagnosis.

[High frequency ventilation in neonatal surgery]. / Ventilation par oscillation à haute fréquence en chirurgie néonatale.

High frequency oscillatory ventilation (HFOV) is one of the artificial ventilation techniques used for the treatment of severe respiratory distress in the neonatal period. We studied (between 1987 and 1992) 57 newborn infants ventilated by HFOV during surgery. The aim was to facilitate the surgical procedure without having any deleterious effects on the gas exchange or the hemodynamic state of the infant. Three groups were studied. Group I (thoracic procedures: oesophageal atresia and pulmonary malformations, n = 25), group II (diaphragmatic hernia, n = 22), group III (abdominal procedures, n = 10). In the thoracic surgery group, no deleterious effect related to the HFOV was reported. The hyperventilation noticed after anaesthetic induction was rapidly corrected by placing the patient in a lateral position. In the three groups, no intraoperative complications related to the HFOV were observed. The diaphragmatic hernia group was divided into two subgroups according to the timing of surgery (emergency surgery, surgery after stabilization). In the latter subgroup, surgery was performed when the ventilation and gas exchange conditions had significantly improved. This subgroup showed the highest survival rate. This technique of peroperative ventilation is specifically used in the thoracic and diaphragmatic procedures of term and preterm newborn infants. It achieves a more stable operative field with less pulmonary expansions and diaphragmatic movements. In spite of the fact that HFOV is seldom used during anaesthesia, this study confirms its safety as well as the simplicity of its monitoring.

[Congenital diaphragmatic hernia: results of the association of preoperative stabilization and oscillation ventilation. (A prospective study of 17 patients)]. / Hernies diaphragmatiques congénitales: résultats de l'association stabilisation préopératoire et ventilation à oscillation. (Etude prospective de 17 patients).

The authors studied the efficacy of ventilation by high frequency oscillation in preoperative stabilization of 17 newborns with diaphragmatic hernia. This prospective study covered the pre-, intra- and postoperative periods. The preparation to surgery lasted 57 +/- 52 hr. The newborns were operated at 61 +/- 46 hr of life and the duration of postoperative mechanical ventilation was 184 +/- 200 hours. Two groups were differentiated retrospectively. The first group (n = 11) comprises neonates in whom a good preoperative stabilization was obtained and who underwent surgery before 48 hours. In this group all children survived at one month of life (one infant died at six months from cardiac malformation during heart surgery). The second group (n = 6) consists of neonates having required a longer time for stabilization. The operation was performed on the fifth day only. After one month, 5 children survived (one newborn died from intractable hypoxaemia at 5 days of life, surgical cure being impossible; 3 infants died belatedly from associated severe malformations). Predictive factors can be individualized: arteriolar-alveolar ratio, associated abnormalities and particularly these concerning heart, oxygenation index at birth, time required to stabilize the newborn condition. Nevertheless, the association of preoperative stabilization and ventilation by high frequency oscillation appears to improve the prognosis of congenital diaphragmatic hernia.

Dorsally displaced extra-articular distal radius fractures fixation: Dorsal IM nailing versus volar plating. A randomized controlled trial.

INTRODUCTION: Fractures of the distal radius are very common and mainly occur in the elderly. There has been an increasing use of locked volar plate fixations which report satisfactory results. However, some authors advocate the use of nail fixation. HYPOTHESIS: The aim of this study is to compare dorsal nail plate versus locked volar plate fixation in the treatment of distal radius fractures with dorsal tilt. MATERIALS AND METHODS: The mean age of the patients was over 50 years. The study included extra-articular distal radius fractures with posterior tilt. We conducted a prospective randomized study between December 2007 and February 2009 including a group of 16 patients treated with a dorsal nail fixation (group 1) and a group of 15 patients managed with a locked volar plate fixation (group II). We analyzed both the clinical results (complications, Range of motion [ROM], tightening strength, Disabilities of the Arm, Shoulder and Hand [DASH] and Mayo Clinic scores) and the radiographic results from A/P and lateral radiographs in the early postoperative period and at 6-month follow-up. RESULTS: ROM toward extension was better in the volar plating subgroup (group I, 42.5°, group II, 57.5°; P<0.05). Pronation mobility was better in the dorsal nail subgroup (group I, 85°; group II, 80°; P<0.05). The locked volar plate fixation subgroup demonstrated a better recovery of the tightening strength as compared with the uninjured side (group I, 78%, group II, 90%, P=0.03). The DASH score was similar in both groups (group I, 22.09±22.9; group II, 20.62±20.3, P>0.05). The Mayo Clinic score was better in the locked volar plate fixation subgroup (group I, 65±13.4; group II, 85.6±19.2; P=0.002). Radiographic results were good in both groups, however anatomical reduction of the volar tilt was significantly better in group II (plate) when compared with the uninjured side. Moreover, we report on two cases of tendinous damages to the long extensor muscle of the thumb in the dorsal nail fixation subgroup despite the use of a minimally invasive implant. CONCLUSION: The management of distal radius fractures with locked volar plate fixation in active elderly patients has proved successful and leads to better results than nail fixation regarding both reduction quality and objective functional scores. LEVEL OF EVIDENCE: Level II, prospective, randomized of low-level.