Long-term results of treatment of congenital idiopathic clubfoot in 187 feet: outcome of the functional "French" method, if necessary completed by soft-tissue release.

BACKGROUND: Two main options for treatment of congenital idiopathic clubfoot are the "French" functional method and the Ponseti method. The goal of this article was to evaluate the results of the functional treatment method, which, if necessary, is completed by a surgical release. PATIENTS AND METHODS: A series of 187 feet (129 patients) underwent functional conservative treatment. At first evaluation, the feet were classified according to the classification of Dimeglio. All patients then underwent daily physiotherapy and splintage, which was progressively stopped during childhood. Among these 187 feet, 85 feet (45.5%) required soft-tissue release to correct the remaining deformity. Surgery, when required, consisted of a complete posterolateral and medial release procedure, combined with a lengthening of the tibialis anterior tendon in most cases and a bony lateral procedure in case of forefoot adduction. RESULTS: At the latest follow-up (14.7 y; range, 7.4 to 23 y), results were "good" or "very good" in almost 98% of feet, according to the Ghanem and Seringe score. Severe feet at first consultation showed a worse result and required surgery more often than did the less severe ones. Among nonoperated feet, very good results were found in 99% of feet, and none had a fair or bad result. The average age at surgery was 2.5 years. Feet operated upon had lower results compared with the others. At last follow-up, among the operated feet, the results were excellent or good in 95% of the feet. The results were fair or bad in 4 cases; all 4 feet had been operated upon more than once. The results were not statistically dependent on age at the time of surgery, but feet operated upon before the age of 2 years had statistically more flattening of the talar dome and subtalar stiffness. CONCLUSIONS: The functional treatment of clubfoot leads to a very good result without the need for surgery in more than half of the patients. The initial severity of the feet is the main factor that influences the final result. The rate of feet not requiring surgery should be increased by recent modifications to the method, including percutaneous Achilles tenotomy. LEVEL OF EVIDENCE: Level IV-retrospective series.

Preventive antireflux surgery in patients with congenital diaphragmatic hernia.

BACKGROUND: Gastroesophageal reflux (GER) is common in children with congenital diaphragmatic hernia (CDH), and the optimal management in these patients is not well established. The aim of this study was to assess whether a preventive fundoplication performed during the first surgery will improve GER and nutritional morbidity in patients with a left CDH. METHODS: Thus we studied one group of 17 patients treated with a one-step antireflux procedure (group A) and a group of 19 patients with only initial diaphragmatic repair (group B) between January 1994 and December 2004. The patients were classified in three stages, mild intermediate and severe form, based on anatomic criteria (liver position and patch requirement). Most of the patients with the severe form of disease were in group A. Clinical charts were compared between the two groups with a mean follow-up of 3 years. RESULTS: For patients with intra-abdominal liver and direct diaphragmatic closure, the duration of hospitalization was significantly longer in group A than in group B (p = 0.08). The incidence of GER was significantly lower in group A (17.6%) than in group B (52.6%) at 1-year follow-up (p < 0.5). In the last group, 30% required a fundoplication before 6 months. Seven patients (19%) required intermittent nutritional supplementation via nasogastric tube feeding; for these patients there was no difference between the two groups. A gastrostomy was performed in only one patient. Twelve percent of patients had growth retardation during most of their first year, again with no difference between the two groups. CONCLUSIONS: Based on the published data, recommendations can be made regarding the efficacy of adding an antireflux surgery procedure to left CDH repair in only patients with intrathoracic liver and/or patch requirement.

[Uroflowmetric functional evaluation of modified Duplay procedure in hypospadias surgery]. / Evaluation fonctionnelle par débitmétrie de l'urétroplastie de Duplay modifiée dans la chirurgie de l'hypospade.

We perform a modified Duplay procedure in our department without incision of the urethral plate for correction of distal hypospadias. The objective of this retrospective study was to analyse the long-term functional and aesthetic results of this technique. Strictures are a frequent complication of hypospadias surgery, but their frequency is often underestimated as they can remain asymptomatic. We decided to systematically detect urethral strictures by performing voiding uroflowmetry in all children over the age of 4 years, i.e. toilet trained, operated by Duplay procedure in our department. The results were compared to the standard results in paediatric populations published in the literature. The maximum flow rate was below the 5th percentile in 20% of cases and the average flow rate was abnormal in 30% of cases. Voiding uroflowmetry is a simple, noninvasive method to detect asymptomatic urethral strictures. Uroflowmetry is essential to evaluate the functional results of surgical procedures used for the treatment of hypospadias.