Surgical treatment of congenital pseudarthrosis of the forearm: Review and quantitative analysis of individual patient data.

There is little scientific evidence on the best surgical treatment for congenital pseudarthrosis of the forearm due to the rarity of this condition (less than 100 cases described in the literature) and the lack of comparative studies. Our aim was to provide evidence in favor of a certain surgical technique. A comprehensive review of the literature was performed using case series and case reports. The statistical analysis was based on individual patient data to mimic a case-control study. A multiple logistic regression was used to assess the effect of each independent variable (neurofibromatosis status, location of the pseudarthrosis, age at first surgery and type of treatment) on bone union at last follow-up (yes/no). The database searches yielded 1112 articles; 55 articles were selected, reporting on 94 cases. Seventy patients had healed completely at the last follow-up (74%). Neither the age at surgery nor the location of the pseudarthrosis was related to union (P>0.7). The patients' neurofibromatosis type 1 status was weakly related to healing (P=0.06). Vascularized fibula transfer had a higher rate of healing (100%) than did non-vascularized bone graft (70%) (P=$0.002). LEVEL OF EVIDENCE: 4 (case-control study of data from case series and case reports).

Closed reduction in late-detected developmental dysplasia of the hip: indications, results and complications.

PURPOSE: The aim of the study was a review of the literature in order to evaluate the results and complications of closed reduction in late-detected developmental dysplasia of the hip (DDH). METHODS: This study consisted of an analysis of the literature relative to late-detected DDH treatment options considering hip congruency, rates of re-dislocation and of avascular necrosis. RESULTS: Gradual closed reduction (Petit-Morel method) appears to be an effective method concerning joint congruency restitution. Dislocation relapse and avascular necrosis are more efficiently prevented with closed versus open reduction. The tendency for spontaneous correction of acetabular dysplasia decreases if closed reduction is performed after 18 months of age. Patient age at the beginning of traction should be considered for the prognosis, with a lower rate of satisfactory results showing after the age of 3 years. CONCLUSION: In our opinion, the Petit-Morel method is a suitable treatment option for children aged between six months and three years with idiopathic DDH.

Lower-limb lengths and angles in children older than six years: Reliability and reference values by EOS® stereoradiography.

BACKGROUND: Lower-limb alignment in children is classically assessed clinically or based on conventional radiography, which is associated with projection bias. Low-dose biplanar radiography was described recently as an alternative to conventional imaging. The primary objective of this study was to assess the reliability of length and angle values inferred from 3D reconstructions in children seen in everyday practice. The secondary objective was to obtain reference values for goniometry parameters in children. HYPOTHESIS: 3D reconstructions can be used to assess the lower limbs in children. MATERIAL AND METHODS: The paediatric reliability study was done in 18 volunteers who were divided into three groups based on whether they were typically developing (TD) children, had skeletal development abnormalities, or had cerebral palsy. The reference data were obtained in 129 TD children. Each study participant underwent biplanar radiography with 3D reconstruction performed by experts and radiology technicians. Goniometry parameters were computed automatically. Reproducibility was assessed based on the intra-class coefficient (ICC) and the ISO 5725 standard (standard deviation of reproducibility, SDR). RESULTS: For length parameters, the ICCs ranged from 0.94 to 1.00 and the SDR from 2.1 to 3.5mm. For angle parameters, the ICC and SDR ranges were 0.60-0.95 and 0.9°-4.6°, respectively. No significant differences were found across experts or radiology technicians. Age-specific reference data are reported. DISCUSSION: These findings confirm the reliability of low-dose biplanar radiography for assessing lower-limb parameters in children seen in clinical practice. In addition, the study provides reference data for commonly measured parameters. LEVEL OF EVIDENCE: IV.

Outcomes of Gartland type III supracondylar fractures treated using Blount's method.

BACKGROUND: Supracondylar fractures of the elbow with major displacement are usually treated by surgical pinning and less often non-operatively as described by Blount. The objective of this study was to assess the clinical and radiological outcomes of Gartland type III supracondylar fractures treated at least 3 years earlier using Blount's method. HYPOTHESIS: Blount's method produces good outcomes after more than 3 years when used to treat Gartland type III supracondylar fractures of the humerus. METHODS: A single-centre retrospective study was done in paediatric patients who were seen within 24hours after sustaining a Gartland type III supracondylar fracture then re-evaluated at least 36 months after treatment. Closed reduction was performed either in the operating room under general anaesthesia or in the radiology suite under procedural sedation. The upper limb was then immobilised for 4 weeks using the cuff-and-collar method described by Blount (mean elbow flexion, 134°). The child was evaluated and radiographs obtained at the outpatient clinic on days 7 and 14. Functional outcomes were assessed using the 1962 SoFCOT criteria and Flynn's criteria and the radiological outcome using Baumann's angle, the humero-condylar angle, and distal fragment rotation. From 2009 to 2013, 22 patients met the inclusion criteria. Mean follow-up was 57 months. RESULTS: Clinical outcomes assessed using the 1962 SoFCOT criteria were very good in 15 patients and good in the remaining 7 patients. The rate of satisfactory outcomes according to Flynn's criteria was 100%. At last follow-up, mean Baumann's angle was 68°, mean humerocondylar angle was 42°, and 2 patients had residual rotation of the distal fragment. CONCLUSION: This work confirms the effectiveness of Blount's method for treating Gartland type III supracondylar fractures. We advocate routine first-line treatment of these fractures using Blount's method in the absence of vascular compromise and instability. LEVEL OF EVIDENCE: IV, retrospective study.

Is non-operative management of childhood neurologic cavovarus foot effective?

INTRODUCTION: Neurologic pes cavus is a progressive deformity that is difficult to treat during growth. The present study reports results of non-operative management, based on the pathophysiology of the deformity, by untwisting nocturnal splint, preceded in some cases by untwisting walking cast. The objective was to assess efficacy and impact on indications for surgery. METHOD: Twenty-three children (35 feet) were included. All had neurologic cavovarus foot, which was progressive in 24 feet (69%) (Charcot-Marie-Tooth disease). Mean age at initiation of treatment was 8.8 years. In 13 feet (38%), treatment began with a untwisting walking cast and in 22 (62%) began directly with the splint. RESULTS: Mean follow-up was 4.5 years. Fifteen feet showed very good and 8 good clinical results (65%); 9 children (12 feet) had moderate or poor results, requiring renewed treatment in 11 feet at a mean 4.5 years after initiation of non-operative treatment. Thirteen patients (56.5%, 21 feet) had reached end of growth by last follow-up; 10 of these feet (48%) had good or very good results without surgery. No triple arthrodeses were required. Factors weighing against good outcome comprised young age at treatment initiation and poor compliance with the splint. Primary deformity severity did not affect outcome. CONCLUSION: The present study demonstrated efficacy for non-operative treatment of childhood neurologic cavovarus foot. Surgery was either avoided (in half of the cases followed up to end of growth) or delayed by a mean 4.5 years, allowing a single procedure before end of growth. We recommend initiating non-operative treatment of childhood cavovarus foot, associating untwisting walking cast and untwisting nocturnal splint, as soon as clinical progression is detected and/or Méary angle on lateral X-ray with block reaches 15°. LEVEL OF EVIDENCE: IV.

Initial treatment of congenital idiopathic clubfoot: Prognostic factors.

BACKGROUND: The initial treatment of congenital idiopathic clubfoot (CIC) is nonoperative. Either the French physiotherapy method or the Ponseti casting method may be used. Whether either method is superior over the other remains unclear. However, the method used initially is not the only determinant of the final outcome. OBJECTIVE: The primary objective was to identify determinants of the final outcome as evaluated based on the need for surgical treatment and on the Ghanem-Seringe score. HYPOTHESIS: Factors associated with the final outcome can be identified. METHODS: Between 2004 and 2011, 100 CICs in 79 patients were treated in two centres, 47 using the French method and 53 the Ponseti method. The Dimeglio grade was determined at baseline and the Ghanem-Seringe score at last follow-up. Surgical procedures (if any), splinting duration, and rehabilitation therapy duration were recorded. The two groups showed no statistically significant differences for Dimeglio grade distribution, time from birth to treatment initiation, or mean follow-up. RESULTS: Factors significantly associated with a poor outcome by univariate analysis were use of the Ponseti method (P=0.0027), older age at last follow-up (P=3×10-4), initial Dimeglio grade (P=7×10-5), and need for surgery (P=10-5); no significant effect was found for splinting duration, rehabilitation duration, bilateral involvement, or antenatal diagnosis. By multivariate analysis, factors independently associated with a poor prognosis were older age at last follow-up, Dimeglio grade, and need for surgery. CONCLUSION: This study confirms the major prognostic significance of initial severity (Dimeglio grade) on the final outcome. The data do not firmly establish that one method is superior over the other. Nevertheless, the need for percutaneous Achilles tenotomy with the Ponseti method leads us to prefer the French physiotherapy method. LEVEL OF EVIDENCE: IV, retrospective study.

Congenital dislocation of the knee at birth - Part I: Clinical signs and classification.

INTRODUCTION: Congenital dislocation of the knee (CDK) is rare, and clinical semiology at birth is not always suitably analyzed. Existing classifications fail to guide treatment. The aim of the present study was to develop a CDK classification for the neonatal period. HYPOTHESIS: A classification based on neonatal severity of clinical signs is easy to implement on simple criteria. MATERIAL AND METHODS: Fifty-one CDKs (40 patients) seen neonatally were included. Three types could be distinguished in terms of reduction and stability: type I, easily reducible CDK, with reduction snap when the femoral condyles pass in flexion, remaining stable in flexion; type II, "recalcitrant" dislocation, reducible by posteroanterior "piston" but unstable, with iterative dislocation once posteroanterior pressure on the condyles is relaxed; and type III, irreducible. The number of anterior skin grooves, global range of motion, flexion deficit and reduction stability were noted for each type. RESULTS: Mean age at first consultation was 5.6 days (range: 0-30). CDK was type I, II and III in respectively 28, 16 and 7 cases. Number of skin grooves, flexion and baseline range of motion were greater in type I than types II and III. CONCLUSION: The present neonatal clinical classification is original, logical and simple. It may be useful for prognosis and guiding treatment. LEVEL OF EVIDENCE: IV, single-center retrospective series.

Congenital dislocation of the knee at birth - Part 2: Impact of a new classification on treatment strategies, results and prognostic factors.

INTRODUCTION: An original classification of congenital dislocation of the knee (CDK) was drawn up, based on neonatal semiology. The objective of the present study was to assess impact on treatment decision-making and prognosis. MATERIAL AND METHODS: Fifty-one CDKs in 40 patients were classified neonatally into 3 types: I, reducible (n=28); II, recalcitrant (n=16); and III, irreducible (n=7). Number of anterior skin grooves, range of motion (RoM), flexion deficit and reduction stability were recorded. Depending on reducibility, treatment comprised: physiotherapy with splints, traction with cast immobilization, or surgery. At follow-up, knees were assessed in terms of RoM and stability. RESULTS: Mean age at first consultation was 5.6 days (range: 0-30). Mean age at follow-up was 9 years (range: 1-26). Physiotherapy with splinting achieved stable reduction in all type-I knees. Five type-II knees (31%) required traction, none of which needed surgery. Four type-III knees (57%) required surgery. Outcome was good or excellent in 82% of type-I knees, good in 68% of type II and poor in all type-III knees. CONCLUSION: The study confirmed the relevance of the present neonatal classification to treatment, with increasing rates of surgical indication and decreasing rates of satisfactory outcome from types I to III. Therapeutic attitude can be graded according to severity of CDK. LEVEL OF EVIDENCE: IV, single-center retrospective series.

Too-long calcaneal process: Results of surgical treatment and prognostic factors.

INTRODUCTION: The too-long anterior process (TLAP) can be responsible for ankle pain or repeated sprains in children or adolescents. The objective of this study was to assess the results of TLAP surgical treatment and to analyze influencing factors in case of this surgery's failure. MATERIAL AND METHODS: Retrospective single-center study conducted from 2009 to 2012 including all patients under 18 years of age for a TLAP with follow-up equal to or longer than 1 year. The results of surgical treatment were assessed using the AOFAS score. Failure was defined as no significant improvement in the AOFAS score at the last follow-up. HYPOTHESIS: Predictive factors of the result of surgical treatment for TLAP can be identified. RESULTS: At the mean follow-up of 2.5 years, 35 patients (43 feet) fulfilled the inclusion criteria. Thirteen feet (30%) presented surgical failure. According to the AOFAS score, the results were excellent in 30 feet (70%), good in four (9%), fair in five (12%), and poor in four (9%). Surgical failure was influenced by the patient's age at the onset of symptoms and at the time of surgery, the degree of functional limitation, the duration of symptoms before surgery, the number of sprains, and gender (P<0.05). CONCLUSION: Firstly, in this pediatric population with its high functional demand, the overall rate of failure of TLAP surgery was 30%. Secondly, the factors associated with failure demonstrated made it possible to identify the ideal patient for this surgery: male, with symptom onset between 7 and 10 years of age, who had experienced fewer than 15 sprains, and undergone surgery in the 3 years following the beginning of symptoms. LEVEL OF EVIDENCE: IV.

Outcomes of modified Dega acetabuloplasty in acetabular dysplasia related to developmental dislocation of the hip.

UNLABELLED: Developmental dislocation of the hip (DDH) is frequently, even after reduction, associated with residual acetabular dysplasia. Various surgical techniques are used to correct this, one of which is Dega acetabuloplasty. This osteotomy technique has, however, rarely been assessed in this particular indication. The present study therefore sought to describe the technical details, report clinical and radiological results, and present limitations. HYPOTHESIS: Unlike reorientation osteotomy in children, Dega acetabuloplasty does not lead to a high rate of acetabular retroversion at the end of growth. PATIENTS AND METHODS: Sixteen Dega acetabuloplasties in 15 patients were assessed on joint range of motion, limp, lower limb length discrepancy and impaired everyday activity, pre-operatively and at end of follow-up. Hips were classified following Wicart et al. (2003). Radiologic assessment comprised Wiberg angle and acetabular index, pre- and post-operatively and at follow-up. Acetabular retroversion was analyzed by crossover sign, and hips were classified following Severin. RESULTS: Median age at surgery was 3 years (range, 1.1-12.2 years) and 10 years (6.4-17.8) at end of follow-up. At end of follow-up, all hips were pain-free and classified as Wicart A, and all activities were allowed. Radiologically, hips were classified as Severin I, II or IV, in 11 (68.5%), 4 (25%) and 1 (6.5%) cases respectively. Wiberg angle rose from a mean 3.3° (-30° to 30°) to 23° (10° to 38°) and acetabular index fell from a mean 31° (25° to 45°) to 20° (5° to 30°) with surgery, and both continued to improve over follow-up: 26° (12-45°) and 13° (3-24°) respectively (P<0.05). Acetabular retroversion was found in 2 of the 10 hips with Y cartilage fusion. DISCUSSION: Modified Dega acetabuloplasty was effective in correcting acetabular dysplasia in DDH. Functional and radiological results were good, with a low rate of acetabular retroversion (2/10), unlike with other techniques. LEVEL OF EVIDENCE: Level IV. Therapeutic study.

Paralytic congenital talipes equinovarus of unknown origin: A new entity. Multicenter study of 42 cases.

BACKGROUND: Paralysis of the lateral and/or anterior leg muscles can lead to relapse of treated talipes equinovarus. HYPOTHESIS: The muscle function impairment is due to isolated permanent paralysis, and early palliative tendon transfer may prevent recurrence of the deformity. MATERIAL AND METHODS: Forty-two cases of congenital talipes equinovarus that recurred after conservative therapy were reviewed after a mean follow-up of 10 years. In 39 cases, second-line surgery was performed (posteromedial release, n=33; and muscle transfer, n=26). Outcomes were evaluated clinically. RESULTS: Separating the cases into two groups, based on whether muscle transfer was performed, showed a statistically significant difference: muscle transfer intended to restore eversion and/or dorsal flexion of the foot was associated with significantly better functional outcomes. DISCUSSION: In addition to providing etiological insights, the identification of paralysis in patients with talipes equinovarus can influence treatment decisions, depending on the nature of the muscle deficiencies, with the goal of preventing recurrences. Early muscle transfer to restore eversion and/or dorsal flexion of the foot may provide the best functional outcomes by minimizing the need for soft-tissue release. LEVEL OF EVIDENCE: IV, retrospective multicentre study.

Brachial plexus birth palsy shoulder deformity treatment using subscapularis release combined to tendons transfer.

INTRODUCTION: One possible sequela of obstetric brachial plexus palsy (OP) is impaired external rotation (ER) of the shoulder which, in addition to its functional consequences, can generate a posterior humeral head subluxation or dislocation. The goal of the present study was to assess medium-term clinical and radiological results of release of the subscapularis muscle with transfer of the latissimus dorsi and teres major muscles. PATIENTS AND METHODS: From 1985 to 1995, a continuous series of 32 OP patients underwent subscapularis muscle release, associated in 24 cases to muscle transfer. Mean age was 2.5 years (range, 1-9.2 years). Shoulder function was assessed by measurement of passive ER and graded according to the modified Mallet classification at 1, 5 and 10 years' follow-up or before revision. The evolution of the glenohumeral deformity was assessed on CT images of glenoid retroversion and the humeral head subluxation (% of humeral head covered), before and 5 years after surgery. RESULTS: Mean postoperative follow-up was 9.5+/-5.6 years. Treatment brought significant improvement in passive ER (mean preoperative and 1-year follow-up values: -10 degrees and 52 degrees, respectively). This explained the good modified Mallet score at 1 year: mean=18.4/25. Subsequent significant progressive degradation was noted: 10 years postoperatively, mean ER amplitude and modified Mallet score were respectively 13 degrees and 15.8. The CT study showed correction of the glenoid retroversion (mean preoperative and 5-year follow-up values: 29 degrees and 18 degrees, respectively), and of the humeral head subluxation (mean preoperative and 5-year follow-up values: 25 and 39%, respectively). Surgical revision was indicated six times (five patients): two latissimus dorsi and teres major transfers (not performed initially) and four derotational humeral osteotomies. Three-quarters of the patients who did not initially have muscle transfer had to be reoperated or else showed ER insufficiency at last follow-up. DISCUSSION AND CONCLUSION: Surgical treatment produces objective functional gain, even if this diminishes over time. Moreover, it prevents or corrects posterior subluxation of the shoulder. It is indicated when passive ER amplitude is negative. It seems advisable to associate release to muscle transfer. LEVEL OF EVIDENCE: Level IV Retrospective study.

Congenital pseudarthrosis of the tibia: an atypical proximal location.

UNLABELLED: Proximal location of congenital pseudarthrosis of the tibia (CPT) is uncommon, and its management challenging, risking to end in amputation. We here report a case of proximal CPT managed in a limb-sparing perspective and followed up until the end of growth. A 17-year-old girl presented with type-1 neurofibromatosis and proximal CPT. Initial X-ray showed severe pseudarthrosis of the tibia with bone atrophy, 12-cm shortening and femorotibial and femoropatellar dislocation. Inter-tibiofibular graft and fibular tibialization were performed. At end of follow-up (age 33 years), fusion had been obtained. For orthoprosthetic and cosmetic reasons, a Boyd amputation of the tarsus was performed when the patient was 22 years of age. The functional result was very good, with 0-100 degrees knee mobility. CPT, when proximal, completely disorganizes the knee joint, which is otherwise usually unaffected by this pathology. To achieve a good result, a limb-sparing treatment should combine correction of the tibial axis and of the dislocation of the knee, fibula osteosynthesis and bone graft. LEVEL OF EVIDENCE: Level IV retrospective

Recurrent club-foot deformity following previous soft-tissue release: mid-term outcome after revision surgery.

The results of further soft-tissue release of 79 feet in 60 children with recurrent idiopathic congenital talipes equinovarus were evaluated. The mean age of the children at the time of re-operation was 5.8 years (15 months to 14.5 years). Soft-tissue release was performed in all 79 feet and combined with distal calcaneal excision in 52 feet. The mean follow-up was 12 years (4 to 32). At the latest follow-up the result was excellent or good in 61 feet (77%) according to the Ghanem and Seringe scoring system. The results was considered as fair in 14 feet (18%), all of whom had functional problems and eight had anatomical abnormalities. Four feet (5%) were graded as poor on both functional and anatomical grounds. The results were independent of the age at which revision was undertaken.

Closed reduction with traction for developmental dysplasia of the hip in children aged between one and five years.

The treatment of developmental dysplasia of the hip diagnosed after the first year of life remains controversial. A series of 36 children (47 hips), aged between one and 4.9 years underwent gradual closed reduction using the Petit-Morel method. A pelvic osteotomy was required in 43 hips (91.5%). The patients whose hips did not require pelvic osteotomy were among the youngest. The mean age at final follow-up was 16.1 years (11.3 to 32). The mean follow-up was 14.3 years (10 to 30). At the latest follow-up, 44 hips (93.6%) were graded as excellent or good according to the Severin classification. Closed reduction failed in only two hips (4.3%) which then required open reduction. Mild avascular necrosis was observed in one (2.1%). The accuracy of the reduction and associated low complication rate justify the use of the Petit-Morel technique as the treatment of choice for developmental dysplasia of the hip in patients aged between one and five years.

The incidence and treatment of rocker bottom deformity as a complication of the conservative treatment of idiopathic congenital clubfoot.

Rocker bottom deformity may occur during the conservative treatment of idiopathic congenital clubfoot. Between 1975 and 1996, we treated 715 patients (1120 clubfeet) conservatively. A total of 23 patients (36 feet; 3.2%) developed a rocker bottom deformity. It is these patients that we have studied. The pathoanatomy of the rocker bottom deformity is characterised by a plantar convexity appearing between three and six months of age with the hindfoot equinus position remaining constant. The convexity initially involves the medial column, radiologically identified by the talo-first metatarsal angle and secondly by the lateral column, revealed radiologically as the calcaneo-fifth metatarsal angle. The apex of the deformity is usually at the midtrasal with a dorsal calcaneocuboid subluxation. Ideal management of clubfoot deformity should avoid this complication, with adequate manipulation and splinting and early Achilles' percutaneous tenotomy if plantar convexity occurs. Adequate soft-tissue release provides satisfactory correction for rocker bottom deformity. However, this deformity requires more extensive and complex procedures than the standard surgical treatment of clubfoot. The need for lateral radiographs to ensure that the rocker bottom deformity is recognised early, is demonstrated.

[Metal-metal-backed polyethylene cemented hip arthroplasty: mid-term results]. / Arthroplastie de hanche a couple métal-metal sur polyéthylène cimenté: Résultats a moyen terme.

PURPOSE OF THE STUDY: Metal-on-metal bearings in total hip arthroplasty may, in theory, provide an effective answer to osteolysis in active patients. The purpose of this retrospective study was to evaluate the results of a consecutive series of Metasul total hip arthroplasties with a cemented socket. MATERIAL AND METHODS: The series was composed of 28 total hip arthroplasties in 23 patients (13 women and 10 men). The mean age at operation was 44 +/- 8.3 years (range 22-59 years). The initial diagnosis was osteoarthritis (14 hips), osteonecrosis of the femoral head (11 hips) and rheumatoid arthritis (3 hips). Cemented cups with a metal articulation surface molded into the polyethylene were used. The cup was articulated with a 28-mm metallic head. Cemented stems were used in 27 hips, whereas a hydroxyapatite coated stem was implanted in one hip. RESULTS: One hip required revision for deep infection five months postoperatively. One patient (one hip) was lost to follow-up. Twenty-six hips were evaluated at an average 31-month follow-up (range 12-47 months). All hips were rated excellent or very good. Radiographically, seven hips (27%) had a progressive acetabular radiolucent line, including three complete radiolucent lines. The latter always were located at the bone-cement interface. No implant migration was noted. In these cases, the mean socket diameter was lower than for the rest of the cohort (p < 0.001). DISCUSSION AND CONCLUSION: Progression of acetabular radiolucent lines remains of concern in this series of Metasul artificial hips. It is hypothesized that the diminution of polyethylene thickness has led to an increased rigidity of the socket, resulting in a higher rate of constraints at the bone-cement interface. Special attention must be given to these hips.

Compact optical data processor employing holographic reflective lenses.

A compact optical data processor is described that employs holographic reflective lenses. The processor is inexpensive and requires one-half of the length of the optical bench as that required for using glass lenses. The fabrication of the holographic lenses is described, and the results of optical processing reported. The results show that an inexpensive data processor employing holographic lenses is a feasible project. The processor may find use for onboard optical processing on spacecrafts and satellites. The most distinguishing characteristic of such a processor is its extreme light weight. The angular alignment tolerances for holographic lenses are very low. The processor must, therefore, be made rugged, designed, and mounted to withstand vibrations, shocks, and other environmental problems associated with spacecrafts and satellites.