[The unsightly chest: Analysis and anomaly. Curative or palliative approach?] / Le thorax disgracieux : analyse et anomalie. Approche curative ou palliative ?

Anterior chest wall deformity are mostly represented by pectus excavatum, which is a depression of the chondrosternal plastron from the 3rd to the 7th pairs of the costal cartilages, then by pectus carinatum which conversely represents a protrusion of this plastron. The major esthetic and psychosocial impact is not to be demonstrated anymore whereas the cardiopulmonary functional impact remains still highly debated. Regarding the management, curative surgical techniques such as Wurtz's sub-perichondrial simplified sternochondroplasty or Nuss' minimaly invasive technique are opposed to palliative filling technique such as customized silicone implant, lipostructure and flaps. In addition to these there are non-surgical techniques like suction bells (Vacuum Bell®) for pectus excavatum or compressive orthotic bracing for pectus carinatum. The morbidity and the mortality related to some of the heavy surgeries must be weighed up with esthetic, functional or both surgical indications in order to choose the proper management. The other known deformities are much rarer. Pectus arcuatum is a combined type requiring the same management principles. Sternal cleft is caused by a fusion defect of the sternal bars, which must be treated mainly by neonatal surgery. Acquired restrictive thoracic dystrophy is a consequence of early curative surgery.

Evolution of slipped capital femoral epiphysis after in situ screw fixation at a mean 11 years' follow-up: a 222 case series.

INTRODUCTION: Slipped capital femoral epiphysis (SCFE) can lead to hip impingement, more or less rapidly depending on initial slippage severity and on surgical technique. Various surgical options are applicable, including in situ fixation (ISF). The aim of the present study was to look for long-term signs of radiological impingement in hips treated for SCFE by IFS, in order to identify a slip threshold beyond which impingement more regularly appears. MATERIAL AND METHODS: A multicenter retrospective study assessed the clinical and radiological evolution of patients operated on by ISF for SCFE, with a minimum 10 year's follow-up. Coxometric analysis of postoperative and last follow-up radiographs was performed. Functional outcome was assessed on Oxford hip score and radiographic osteoarthritis on the Tönnis classification. Alpha angle was measured on lateral views to highlight hip impingement. RESULTS: Two hundred and twenty-two hips were included, with a mean 11.2 years' follow-up. Mean age at diagnosis was 12.8 years. Mean preoperative Southwick angle was 38.8°, with 43% of hips at stage I, 42% at stage II and 15% at stage III. At latest follow-up, mean Oxford score was 14.86, with 88% of hips rated Tönnis 0 or I. Only 15 cases of impingement were diagnosed. There seemed to be a non-significant trend for hip impingement in SCFE exceeding 35°. CONCLUSION: ISF led to hip impingement in moderate to severe initial epiphyseal displacement. However, in smaller displacement, the consequences were milder, with perfectly satisfactory function scores and no clinical or radiological evidence of impingement. The threshold seemed to be around 35° slippage, beyond which other surgical options than ISF should be considered. Thus, it seems reasonable to propose isolated ISF in SCFE<35° and to treat symptomatic impingement by surgery in stage II slips.

"Femoroacetabular impingement". Legg-Calve-Perthes disease: from childhood to adulthood.

OBJECTIVES: The objective of this study was to investigate cases of femoroacetabular impingement (FAI) and analyze the risk factors for a painful hip at skeletal maturity after Perthes disease. We hypothesized that FAI occurs as a sequela of Perthes disease and that coxa plana and triple osteotomy of the pelvis (TOP) may be risk factors. METHODS: Ninety-five hips were included from 1981 to 2011, 56 of which were operated on with TOP (53) or shelf acetabuloplasty (3). The results were evaluated at a mean 13years of follow-up (range, 2-23years) with Oxford score and hip radiograph analysis including the Stulberg grade, coxometry, and presence of a femoral bump. FAI was characterized by positional hip pain with preserved joint space and aspherical/nonspherical femoral head. RESULTS: The Oxford score was optimal (12) in 79 hips (75%) and 20 or above in nine hips (9.5%). Seventeen hips were rated Stulberg I (18%), 36 Stulberg II (38%), 27 Stulberg III (28%), and 15 Stulberg IV or V (16%). The average acetabular angle was 10° (range, -4 to 25), VCE 41.5° (range, 18-80), and VCA 38.5° (range, 13-70). A femoral bump was noted in 31 hips (33%). Five cases of FAI were managed operatively with at least pain relief. Hip pain at the latest follow-up correlated with coxa plana (P=0.0003) and femoral bump (P=0.007). No significant correlation was found with a history of hip surgery or coxometry parameters. CONCLUSION: Perthes hips bear risk for later FAI. Risk factors include coxa plana and femoral bump. In case of TOP, it is advocated to avoid excessive tilt, which may cause FAI. LEVEL OF EVIDENCE: IV.

Unpredictability of hip behavior in Dyggve-Melchior-Clausen syndrome: a mid-term assessment of siblings.

Dyggve-Melchior-Clausen syndrome is a rare spondylo-epiphyseal disease, which almost constantly leads to both bilateral hip degeneration and dislocation. Few authors have reported to date the surgical management of this orthopaedic disorder. We present two new cases affecting siblings. One brother was treated by unilateral triple pelvic osteotomy combined with varus osteotomy of the proximal femur; the other was treated by bilateral Pemberton osteotomies with varus osteotomy of the proximal femur. At a respective 5-year and 3-year follow-up delay, both cases had evolved towards progressive subluxation recurrence along with severe hip degeneration. Based on both our experience and literature review, it seems that one should avoid operating these hips unless pain renders surgery mandatory. Total hip arthroplasty seems the only reliable surgical solution at the adult age and paediatric surgeons should keep in mind that previous femoral osteotomies will make it more challenging for adult orthopaedic surgeons to implant on a remodeled anatomy.

Congenital high scapula (Sprengel's deformity): four cases.

We report a series of four cases of congenital high scapula (or Sprengel's deformity) diagnosed and followed in our establishment. The main feature of this very rare congenital malformation of the pectoral girdle is an abnormally high, more or less dysmorphic scapula. A congenitally high scapula is often discovered in young children, when consequences for aesthetics, and sometimes functional difficulties, are brought to light. When surgical treatment is envisaged, imaging is recommended to diagnose a supernumerary structure, ossified (an omovertebral bone) or not (a fibrous and/or cartilaginous connection), extending from the scapula to the cervical spine. This needs to be resected. A CT scan is essential for detecting an omovertebral bone and the vertebral bone abnormalities that are often associated with it. MRI and ultrasound are very useful for assessing any fibrous and/or cartilaginous components. An ultrasound examination has the undeniable advantage of being quick and easy in these young children.

[Clostridium difficile reactive arthritis in a 7-year-old child]. / Polyarthrite réactionnelle àClostridium difficile chez un enfant de 7ans.

Clostridium difficile reactive arthritis is a rare disease; only 5 pediatric cases have been reported in the literature. Its diagnosis is challenging. It manifests as asymmetric aseptic poly- or oligoarthritis, contemporary to infectious colitis, usually after a period of antibiotic therapy. We report a new case in a 7-year-old boy who presented with unusual polyarthritis affecting 12 joints 1 month after antibiotic therapy with amoxicillin-clavulanate. Punctures of both hip joints proved sterile but significantly improved symptoms. Diarrheic stool cultures during hospitalization provided the diagnosis. Antibiotic therapy using metronidazole completely resolved pain and joint swelling within a week. After 1 year of follow-up, there has been no recurrence. We present a review of the literature on this disease and underline the advantages of joint aspiration in this condition with the dual aim of not missing septic arthritis and effectively relieving pain.

Progressive anterior vertebral fusion: a report of three cases.

We report a series of three cases of progressive anterior vertebral fusion diagnosed and monitored in our establishment. This very rare condition was discovered in young children while exploring a spinal deformity. With X-rays of the thoracolumbar spine it was possible to make a positive diagnosis and ensure follow-up. The radiographic semeiotics are characteristic and combine anterior pinching of the disc, well-delimited erosion of the anterior vertebral corners and anterior then posterior intervertebral ankylosis. MRI is very useful for assessing the extent of the intervertebral ankylosis and the condition of the residual discs, without irradiation. The condition develops over several months or years. Conservative treatment is usually sufficient.

Complications of the Luque-Galveston scoliosis correction technique in paediatric cerebral palsy.

PURPOSE OF THE STUDY: Severe scoliosis is a very frequent condition in cerebral palsy children (CP). It is surgically managed, with unit rod instrumentation being the gold standard in English-speaking countries. The purpose of this work was to report on a small, homogeneous series of non-ambulatory, quadriplegic, spastic patients treated by the Luque-Galveston technique in Strasbourg, France. We present the radiographic outcome of the technique along with a full description of any post-operative complications encountered. MATERIALS AND METHODS: Twenty-eight children were operated on according to the Luque-Galveston technique between January 1997 and January 2006. This instrumentation, with fusion, included the whole spine from the sacrum to level T2. All procedures were performed as a one-stage posterior arthrodesis. The spinal deformities were single thoraco-lumbar curvatures, except in one patient. Both curve magnitude and pelvic obliquity were measured by X-ray pre-operatively, post-operatively and after longest follow-up (over 24 months). Our study focused on the rate of complications of this treatment. Only 16 patients out of 28 were tracked since the remaining 12 were lost to follow-up. RESULTS: Mean curve magnitude was corrected from 80 degrees to 34.8 degrees (mean correction, 56.5%), and pelvic obliquity, from 20.9 degrees to 4.2 degrees (mean correction, 79.6%). Loss of correction at average 3.46-year follow-up was 3.9 degrees of curve magnitude and 2.7 degrees of pelvic obliquity. Mean operating time was 301.5 minutes, and average blood loss was 861.9 ml. Patients were discharged from hospital after an average 19.5-day stay, including mean 8.4-day intensive care unit stay. A single major complication, monocular blindness, occurred during the procedure, probably resulting from air embolism. Post-operative complications (totaling 57.1% of our 28 patients) were: one death, three pneumothoraxes, six segmental atelectasias, seven pneumonias and one superficial wound infection. Late-onset complications (totaling 56.2% of our 16 patients at latest follow-up) were: seven broken sublaminar wires, one iliac perforation by the rod, one skin irritation from extreme malnutrition needing hardware removal, and three superficial sacral decubitus ulcers. DISCUSSION: Our correction rate in children affected by CP and manifesting severe scoliosis is similar to that reported in the literature by different surgical teams. Moreover, we did not observe any deep wound infection, haematoma, septicaemia, neurological and digestive complications. Late-onset complications mainly involved asymptomatic sublaminar wire breakage at the two uppermost levels, but no major complication was due to hardware failure, and vertebral fracture did not occur. There was no need for re-intervention because of the hardware, except for one case in which extreme malnutrition provoked skin conflict with the rod. We encountered 10 "windshield wiper" effects in the iliac bone, but we believe they cannot be considered as complications since they seemed to disappear after fusion was fully obtained. Last but not least, unit rod instrumentation is not very expensive compared to more modern techniques. CONCLUSION: Correction of scoliosis and pelvic obliquity, attributed to CP in non-ambulatory children, by the Luque-Galveston technique is both an effective and safe choice in such an indication. Moreover, it is far less expensive than most other techniques, an aspect which should be taken into consideration. LEVEL OF EVIDENCE: Level IV retrospective therapeutic study.

Meningococcal purpura fulminans in children: I. Initial orthopedic management.

BACKGROUND: Purpura fulminans is a rare and extremely severe infection, mostly due to Neisseria meningitidis frequently causing early orthopedic lesions. Few studies have reported on the initial surgical management of acute purpura fulminans. The aim of this study is to look at the predictive factors in orthopedic outcome in light of the initial surgical management in children surviving initial resuscitation. METHODS: Nineteen patients referred to our institution between 1987 and 2005 were taken care of at the very beginning of the purpura fulminans. All cases were retrospectively reviewed so as to collect information on the total skin necrosis, vascular insufficiency, gangrene, and total duration of vasopressive treatment. RESULTS: All patients had multiorgan failure; only one never developed any skin necrosis or ischemia. Eighteen patients lost tissue, leading to 22 skin grafts, including two total skin grafts. There was only one graft failure. Thirteen patients were concerned by an amputation, representing, in total, 54 fingers, 36 toes, two transmetatarsal, and ten transtibial below-knee amputations, with a mean delay of 4 weeks after onset of the disease. Necrosis seems to affect mainly the lower limbs, but there is no predictive factor that impacted on the orthopedic outcome. We did not perform any fasciotomy or compartment pressure measurement to avoid non-perfusion worsening; nonetheless, our outcome in this series is comparable to existing series in the literature. V.A.C.(®) therapy could be promising regarding the management of skin necrosis in this particular context. While suffering from general multiorgan failure, great care should be observed not to miss any additional osseous or articular infection, as some patients also develop local osteitis and osteomyelitis that are often not diagnosed. CONCLUSIONS: We do not advocate very early surgery during the acute phase of purpura fulminans, as it does not change the orthopedic outcome in these children. By performing amputations and skin coverage some time after the acute phase, we obtained similar results to those found in the literature.

Meningococcal purpura fulminans in children. II: Late orthopedic sequelae management.

BACKGROUND: Purpura fulminans is a rare and extremely severe infection, mostly due to Neisseria meningitidis. Nineteen patients were followed up immediately after the initial multivisceral failure in order to diagnose late-onset orthopedic sequelae. We report our experience with these 19 patients, in light of our medical follow-up protocol and surgical management. MATERIALS AND METHODS: Nineteen patients were referred for acute purpura fulminans between 1987 and 2005 to our institution and followed up prospectively until the present. We collected information on all diagnosed orthopedic sequelae, all surgical procedures performed, and the actual orthopedic outcome. RESULTS: Fourteen patients developed at least one orthopedic sequel after a mean of 2 years delay, with a mean of 8.65 years follow-up (range 3-22 years). The most common presentation was lower limb physeal growth plate arrest in eight patients involving 18 growth plates, leading to five limb length discrepancies and 12 significant knee and/or ankle deviations. Patients were treated by completing epiphysiodesis in addition to limb lengthening and/or reaxation osteotomies, except for two patients, in which epiphysiolysis was performed. All outcomes are, to date, satisfactory, with both knee and ankle axes within the physiological range. Among the seven patients who underwent below-knee amputation, six needed stump revision because of skin conflict (4) or prosthetics misadaptation due to upper tibial varus (2). Regarding the upper limb, three patients presented with four cicatricial scar bands, one located on a ring finger, two at the first commissure, and one at the wrist (all were successfully treated by enlargement Z-plasties). Two patients developed hip avascular necrosis. CONCLUSION: It is important for children diagnosed with meningococcal purpura fulminans to be followed up closely starting from the very beginning by a pediatric orthopedic surgeon. It ensures that late-onset orthopedic sequelae will be diagnosed early. In accordance to the literature, this study highlights the high rate of lower limb epiphysiodesis, above all other types of sequelae. This study reports a possible link between purpura fulminans and avascular necrosis of the hip.

The future of robotics in hand surgery.

Robotics has spread over many surgical fields over the last decade: orthopaedic, cardiovascular, urologic, gynaecologic surgery and various other types of surgery. There are five different types of robots: passive, semiactive and active robots, telemanipulators and simulators. Hand surgery is at a crossroad between orthopaedic surgery, plastic surgery and microsurgery; it has to deal with fixing all sorts of tissues from bone to soft tissues. To our knowledge, there is not any paper focusing on potential clinical applications in this realm, even though robotics could be helpful for hand surgery. One must point out the numerous works on bone tissue with regard to passive robots (such as fluoroscopic navigation as an ancillary for percutaneous screwing in the scaphoid bone). Telemanipulators, especially in microsurgery, can improve surgical motion by suppressing physiological tremor thanks to movement demultiplication (experimental vascular and nervous sutures previously published). To date, the robotic technology has not yet become simple-to-use, cheap and flawless but in the future, it will probably be of great technical help, and even allow remote-controlled surgery overseas.

Telemicrosurgery: a feasibility study in a rat model.

Telesurgery is frequently used in cardiac, urologic, gynaecologic or digestive surgery. Significant advances are due to this technology: reduction of the operative time, safety and precision of the surgical gesture, reduction of bleeding and more comfort for the surgeon. However, no telesurgical experiment has been reported yet in microsurgery with 10-0 nylon sutures. The aim of the present work was to assess the feasibility of vascular anastomosis by a telemicrosurgical technique. The material used for this experiment consisted of two Wistar rats, a standard set of surgical instruments and a Da Vinci S (Intuitive Surgical) telemanipulation system. Rats were prepared in compliance with the current regulation. The rat tail was approached by cutaneous incision. The following surgical steps were carried out by telemicrosurgery: dissection, fitting of a vascular clamp, section of the artery and suture by 10-0 nylon separate stitches. Following anastomoses, patency tests were carried out and showed the suture effectiveness. The procedure lasted one hour in both cases. Physiologic tremor was abolished by the telemicrosurgical interface. In this study, the operator's pronosupination amplitude was 360 degrees . Optical magnification was the same as with a conventional operative microscope. The adjunction of a third articulated arm improved the ergonomics of the working space. Preliminary results are in favour of the feasibility of telemicrosurgery. The learning curve was astonishingly short. It remains to be used in human clinical practice.

Use of end caps in elastic stable intramedullary nailing of femoral and tibial unstable fractures in children: preliminary results in 11 fractures.

BACKGROUND: Elastic stable intramedullary nailing (ESIN) is used routinely world-wide for treating femoral and tibial shaft fractures in children before skeletal maturity. Overall, ESIN allows rapid limb mobilisation with few complications. However, many centres have experienced some complications resulting from secondary fracture displacement, especially in heavy adolescents and in spiroid or complex fractures due to changes in the nail's position, leading to limb shortening, malrotation and malalignment. End caps were designed by the AO expert group to address these complications. PURPOSE: The purpose of this study is to evaluate the efficiency, safety and tolerance of this new device in our first series of ten patients and 11 fractures. METHODS: Prospective follow-up of our first ten patients operated on with end caps. RESULTS: Our results show that there were no serious complications at a mean follow-up of 13.1 months. There was only one 10-mm leg shortening in a patient in whom the end caps could not be properly inserted. There were no infections, no additional pain and no skin irritation. The use of end caps eased the removal of the nails after bone healing, thereby preventing the formation of ossification over the tips of the nails and appeared to protect the skin next to the nail tip. CONCLUSION: These results seem to prove the advantage of using end caps when performing ESIN in lower limb shaft fractures in children. A longer follow-up that includes more patients and a randomised prospective study should be carried out in the future to determine more precisely the indications of this new device.