[Hematogenous osteomyelitis of the calcaneus in children: 26 cases]. / L'ostéomyélite hématogène du calcanéum chez l'enfant: à propos de 26 cas.

PURPOSE OF THE STUDY: Osteomyelitis is rarely observed in the calcaneus; about 3 to 10% of the bone infections in children. The diagnosis is often established late because of the less pronounced symptoms in long-bone localizations. We report a series of 26 cases of osteomyelitis of the calcaneus observed in children. MATERIAL AND METHODS: We studied the clinical history, the diagnostic process and the treatments delivered. Outcomes were assessed in terms of complications, anatomy and function at mean two years follow-up (range one to seven years). RESULTS: There were 15 boys and 11 girls, mean age was seven years (range one month to 13 years). Mean time from symptom onset to consultation was 13 days and mean time from consultation to hospital admission was four days, range one to 29 days. The clinical presentation was not specific. Body temperature was not above 38.5 degrees C in 45% of patients. Symptoms were fever, pain in the rear foot and functional impotency of the lower limb. Eight patients (30%) complained of moderate pain, 18 (70%) of intense pain. The pain was focused far from the calcaneus in six patients, retarding the diagnosis. Laboratory tests did not always reveal signs of inflammation. White cell counts above 10,000 were noted in only 61% of patients. The diagnosis of osteomyelitis of the calcaneus was based on: the plain X-ray, which revealed a defect in the calcaneus (n=12), ultrasound (performed in 19 patients) which revealed calcaneal subperiosteal detachment (n=6), collections in the rear foot (n=3) and soft-tissue thickening (n=4). Bone scintigraphy was performed in one child and showed intense uptake in the calcaneus. Magnetic resonance imaging, performed in one patient, demonstrated an anomalous signal in the calcaneus (high-intensity T(2) and low-intensity T(1) with presence of a subperiosteal abscess). Bacteriology was positive in 53% of the children. Medical treatment was delivered for all patients and 23 underwent a surgical procedure. For one of the three patients treated medically, the diagnosis of osteomyelitis of the calcaneus was clinical, since the plain X-ray was normal, the ultrasound yielded no evidence of abscess formation and the bacteriology was negative; but after two months of antibiotic treatment, bone remodelling was in favour of osteomyelitis of the calcaneus. For the two other patients treated medically, the plain X-ray showed a defect in the calcaneus, which had filled after two months of antibiotics. For the 23 patients treated surgically, the procedure was an evacuation of a subperiosteal abscess for 13 (n=6 nonruptured and 7 ruptured). Surgery revealed a bone lesion in nine children allowing curettage of the defect. Articular involvement was noted in eight cases: subtalar osteoarthritis (n=6) and tibiotarsal arthritis (n=2). Two surgical explorations failed to find any abscess formation; blood cultures confirmed the diagnosis and enabled isolation of the causal germ. Outcome was assessed with a mean follow-up of two years, range one to seven years. Nineteen patients (73%) were free of sequelae. Seven patients (27%) presented poor outcome with significant limitation of motion in the rear foot and ankle ankylosis. Seven patients developed chronic fistules, with persistent discharge at last follow-up. The poor results were observed in patients treated late with mean 17 days before consultation. Six of the seven cases of poor outcome were associated with arthritis involving a calcaneal joint (subtalar and tibiotarsal in two patients and subtalar in four). DISCUSSION: The same pathophysiological phenomenon as observed in long-bone localizations is noted for osteomyelitis of the calcaneus; the calcaneus has an apophysis, which is equivalent to the metaphyseal region of long bones, leading to the bone's vulnerability to hematogenous infection. Late diagnosis can be related to the notion of trauma, the manifestations of osteomyelitis being attributed to ligament injury. The positive diagnosis of osteomyelitis of the calcaneus is often established late because of late consultation (13 days in our series) or the minimal expression of general signs. Magnetic resonance imaging contributes significantly to diagnosis by showing an abnormal bone signal; it can also disclose associated abscess formation. Authors differ in their descriptions of the complications. The analysis of our results shows that the prognosis of osteomyelitis of the calcaneus is related to early diagnosis and management. Associated septic arthritis is an element of poor prognosis.

[Acute hematogenous osteomyelitis of the obturator rim in seven children]. / L'ostéomyélite aiguë hématogène du pourtour du foramen obturé chez l'enfant : à propos de sept cas.

PURPOSE OF THE STUDY: Acute osteomyelitis of the rim of the obturator foramen is rarely reported. The clinical presentation is atypical, making diagnosis a difficult task. We report a series of seven cases of osteomyelitis of the obturator rim which illustrate the different features of this localization. MATERIAL AND METHODS: The series included seven boys with osteomyelitis involving the obturator foramen. We reviewed the clinical history, the diagnostic approach and management. Complications and anatomic outcome were noted at mean three years follow-up (range one to 10 years). RESULTS: Mean age was 9.5 years (five to 12 years). Bilateral involvement was noted in one boy. Mean time from symptom onset to consultation was five days and mean time from consultation to hospitalization was eight days. No specific clinical presentation could be identified. Fever was not a constant feature. Mean body temperature was 38.6 degrees C and was not greater than 38.5 degrees C in four children. Symptoms were limited to hip pain in five cases and abdominopelvic pain was noted in two. Physical examination failed to trigger exquisite ischial or pubic pain in two patients. The osteomyelitis involved the ischiopubic ramus in four cases, the ischium in two with one bilateral case, and the pubis in one. Certain diagnosis was established as follows: MRI findings plus isolation of the pathogenic agent (n=4) ; the plain x-ray showed a defect in the ischiopubic ramus, MRI showed signs favoring osteomyelitis of the ischiopubic ramus and surgery evacuated a purulent collection (n=1) ; strong uptake of the obturator rim on scintigraphy (n=2). Medical treatment was given in all cases and surgery was performed in six patients. Outcome was noted at three years follow-up, range one to 10 years. All patients recovered normal function. There were no complications. DISCUSSION: Hematogenous osteomyelitis of the pelvis is exceptional (2-11 % of cases of osteomyelitis). Localization in the obturator rim is rare. We discuss the specific diagnostic and therapeutic features of this localization. Despite the controversy concerning the treatment of pelvic osteomyelitis and in particular cases involving the obturator rim, prognosis is generally good. No complications have been described in the literature specifically associated with osteomyelitis of the obturator rim.

[Acute hematogenous osteomyelitis of the neck of the femur in children: 28 cases]. / L'ostéomyélite aiguë hématogène du col du fémur chez l'enfant : à propos de 28 cas.

PURPOSE OF THE STUDY: Osteomyelitis of the neck of the femur is uncommon, often with a misleading clinical presentation. We report a series of 28 cases of osteomyelitis of the femoral neck to illustrate the particular clinical and imaging findings related to this localization. MATERIAL AND METHODS: This was a series of 28 children treated in our unit from 1990 through 2004: 17 boys and 11 girls, mean age eight years (range one month to 14 years). We analyzed the data in this series using a standard checklist, which noted the diagnostic and therapeutic measures. Results were analyzed by studying the complications, anatomic and functional outcome at mean follow-up of 3.5 years. RESULTS: Time from symptom onset to consultation was five days on average with a delay of 4.5 days from consultation to hospitalization. Intense pain was noted for eight patients (28%) and total functional incapacity of the limb was noted for 15 (53%). Hip stiffness was observed in 11 patients (39%). The diagnosis of osteomyelitis of the femoral neck was established on the basis of imaging (MRI or scintigraphy) in three patients with bacteriological proof in two, of operative findings which confirmed the neck localization in 19, and on changes in the X-ray image of the neck in six. A positive bacteriology was noted in 71%. The germ was isolated from blood cultures and local samples obtained by arthrotomy in five patients (same germ), only in blood cultures for four, and only in local samples in 11. Met-S Staphylococcus aureus was isolated in 18 patients, Met-R S. aureus in one and a Streptococcus in one. All patients were given medical treatment and 25 underwent surgery. There were five thromboembolic complications and five patients who developed femoral pandiaphysitis. Results were analyzed at mean 3.5 years (range four months to 14 years). Complete hip motion was recovered in 78%. There were four cases of hip stiffness and two cases of ankylosis. Partial cephalic necrosis was noted in two hips and total necrosis of the head and neck in two. DISCUSSION: Little data is available in the literature on isolated osteomyelitis of the femoral neck. Based on the pathogenic mechanisms known for osteomyelitis, an isolated localization in the neck of the femur, with no other site in the hip joint, is quite possible in an early stage of infection. We discuss the specific clinical and imaging features of this localization. Analysis of our findings show that the prognosis of femoral neck osteomyelitis is directly related to time to management. Outcome is poorer when treatment is started late. Prognosis is poor if pandiaphysitis develops.

[Fracture of the ulna and bilateral congenital dislocation of the head of the radius: A case report]. / Fracture de l'ulna et luxation congénitale bilatérale de la tête radiale: à propos d'un cas.

We report a case of bilateral congenital dislocation of the radial head discovered at the time of a fracture of the ulna. The dislocation was missed initially and when considered as part of the Monteggia fracture, raised a problem concerning the therapeutic approach. The purpose of this report is the emphasize the importance of careful physical examination before undertaking treatment of any lesion.

[Supracondylar femoral extension osteotomy for knee flexion contracture correction in poliomyelitic conditions]. / Ostéotomie fémorale supra-condylienne d'extension dans la correction des flexums post-poliomyélitiques du genou.

PURPOSE OF THE STUDY: Knee flexion contracture due to quadriceps paralysis is a major handicap in poliomyelitis patients. The patient has to stabilize the knee with the ipsilateral hand to achieve weight bearing and the deformed knee precludes use of orthopedic devices. Extension can be achieved with supracondylar femoral osteotomy if the knee flexion contracture is less than 30 degrees. We assessed functional and anatomic outcome. MATERIAL AND METHODS: We reviewed the files of 87 patients who had undergone 93 supracondylar femoral osteotomies for knee flexion contracture (6 bilateral cases); mean age was 18 years and mean flexion was 25 degrees. The surgical correction was achieved by diaphyseal metaphyseal impaction with resection of an anterior wedge and preservation of the posterior component of the articulation. If some gluteus maximus activity was retained and the tibiotarsal joint was in a slightly equine position, weight bearing in a stable locked position became an automatic postural event even in case of total paralysis of the quadriceps. Osteotomy was not possible if the contracture flexion was greater than 30 degrees due to excessive tension on the vaculonervous bundles. The procedure was equally impossible in children under 12 years of age due to the risk of recurrence subsequent to migration and callus remodeling with bone growth. RESULTS: Complete extension of the knee was achieved peroperatively in all cases. The most serious complications were three cases of septic arthritis that led to an irreducible stiff knee. In addition, we had two cases of transient paralysis of the common fibular nerve that recovered spontaneously. Bone fusion was achieved in all cases within 30 days. Recurrent flexion contracture was observed in 5 cases and required a revision using the same procedure in 3 or them. Postoperatively, the amplitude gained in knee extension corresponded to the amplitude lost for flexion. Sixty-three patients were able to walk independently without manual stabilization and a knee extension orthesis could be installed for 19 others. Three patients were still unable to walk despite the correction of the knee flexion contracture due to failure of poorly accepted orthopedic devices. DISCUSSION: Several conservative methods (physiotherapy, manipulations, successive corrective casts) and surgical procedures (release of posterior soft tissues, Ilizarov technique) have been proposed for the correction of paralytic knee flexion contracture. Supracondylar femoral osteotomy for extension can be useful after the end of growth if the flexion contracture remains below 30 degrees. The procedure is simple and morbidity is relatively low compared with the regularly successful results. When the flexion contracture exceeds 30 degrees, the supracondylar osteotomy cannot be employed due to the risk of stretching the vasculonervous bundles and due to the instability and disorganization of the lower femur. Progressive correction can be proposed for these patients: regular monitoring of the neurological and vascular situation is required. Functional improvement is considerable after correction of knee flexion contracture. The patients can walk more easily, no longer need to stabilize their knee with their hand, and can benefit from orthopedic devises due to the more favorable biomechanical conditions.