Minimally invasive treatment of displaced intra-articular calcaneal fractures using the balloon kyphoplasty technique: preliminary study.

BACKGROUND: The balloon kyphoplasty approach to the treatment of vertebral fractures can be adapted to achieve the reduction and cement stabilisation of intra-articular compression fractures at other sites, such as the calcaneus. PATIENTS AND METHOD: We studied six patients with a median follow-up of 12 months (range, 6-30 months). Fluoroscopy guidance was used to obtain optimal balloon positioning under the joint depression site. Reduction was achieved by expanding the balloon and stabilisation by injecting the cavity with resorbable tricalcium-phosphate cement in the younger patients and polymethyl-metacrylate cement in the two elderly patients with osteoporosis. No internal fixation was used. RESULTS: No intra-operative, postoperative, or delayed complications were recorded. Median hospital stay length was 4.5 days (range, 3-7 days). All the fractures healed within the usual timeframe, without loss of reduction. Median time to full weight-bearing ambulation was 52.5 days (range, 15-75 days). The functional outcomes correlated with the good anatomic results, with a median American Orthopaedic Foot and Ankle Society score of 87.0 (range, 86-97). DISCUSSION: This preliminary study shows that balloon reduction and cement fixation of intra-articular calcaneal fractures is easy to perform, reproducible, and devoid of specific complications. Good-quality reduction and stabilisation until fracture healing were achieved, and time to recovery of self-sufficiency was short, even in elderly patients with osteoporosis. These results support the use of this minimally invasive technique. LEVEL OF EVIDENCE: Level IV, retrospective study.

Progressive limitation of knee flexion secondary to an accessory quinticeps femoris muscle in a child: a case report and literature review.

We describe a symptomatic, progressive restriction of knee flexion due to an accessory quadriceps femoris in a nine-year-old girl. There was no history or findings of post-injection fibrosis, nor any obvious swelling of the affected quadriceps. At arthroscopy no intra-articular pathology was found. An accessory 'quinticeps femoris' was diagnosed by ultrasonography and MRI. Following excision of the muscle and tendon full flexion of the knee was regained and there was no recurrence of the contracture.

Acute osteomyelitis in children: the pathogenesis revisited?

PURPOSE OF THE STUDY: The present study reviews our experience of acute hematogenous osteomyelitis in 450 children over a period of 20 years from 1985 to 2004 at the Nouméa Territorial Hospital in New Caledonia. The objective was to formulate a new theory of the pathogenesis of this affection and to report our research on the disparity in the pathology between temperate countries and our own tropical Pacific area. PATIENT AND METHODS: Only children with an initially normal X-ray and showing symptoms for less than one week were included in the study. Subacute osteomyelitis, infant osteoarthritis and spinal and sacroiliac joint infections were all excluded. All children were treated according to a preestablished protocol including: clinical examination; blood tests; ultrasound, to determine the presence and size of the periosteal elevation and to exclude soft tissue abscess and frequent pyomyositis. Ultrasound was used in the decision to treat with antibiotics alone or with surgery. Computed Tomography was used for deep structures assessment and medical therapy guidance Surgery was limited to open drainage of the subperiosteal abscess only. Regular follow-up of outpatients was continued until normal blood test and X-ray results were achieved. RESULTS AND DISCUSSION: Four hundred and fifty children with a diagnosis of acute hematogenous osteomyelitis were identified, giving an average incidence of 22 new cases per year (range, 12-35). This incidence was two to five times as high as found in Europe. Fifty-three percent of our cases required surgical drainage (vs. 20 % in Europe). Ethnically, 60 % of the children were Melanesian and 20 % Polynesian (both represented less than 50 % of the local population). A similar incidence, about four times as high as in the population of European descent, was reported in Polynesians by our neighbors in New Zealand. The limbs were affected in 90 % of cases, and specifically lower limbs in 70 %. Multiple osseous lesions and systemic infection were recorded in 43 children (9.5 %). Blood cultures and surgical samples were positive in 80 % of cases, and otherwise negative. All the children were successfully treated, without chronic evolution or sequelae needing secondary surgery. The predominant microorganisms isolated were Staphylococcus aureus, in 81 % of cases, none of which were methicillin-resistant, and group A Streptococcus in 7.5 % of cases. A previous study of soft-tissue S. aureus infection showed the presence of Panton-Valentine Leukocidin (PVL) genes in 89 % of cases. These very infrequent genes are responsible for leukotoxic apoptosis, producing leukocidin, causing local acute aggressiveness. A parallel study, in progress for more than a year, is focusing on detecting PVL genes in S. aureus isolated from acute osteomyelitis: in the first nine children analyzed, PVL genes were likewise detected in 89 % of the S. aureus isolated, with no methicillin resistance. Ultrasonography allowed positive diagnosis in 64 % of cases on the day of admission and 84 % by the second day. Because of this very early presence of subperiosteal abscess at the beginning of the disease, and several other issues raised in the present study, we believe that Trueta's theory of acute osteomyelitis pathogenesis does not provide any logical explanation for our anatomoclinical observations. We believe that the primary focus of infection is in the osteoperiosteal area rather than under the growth plate in the metaphyseal bone. The term of Acute Osteo-Periostitis would therefore be much more suitable. A history of blunt trauma was found in 63 % of cases in the present series, and often reported in the literature. We speculate that two forms of infection fixation may develop: a local form, where bacteria carried by the blood stream reach a subperiosteal edema or hematoma secondary to blunt trauma, which is in our opinion the most frequent cause; and a general form, where fixation occurs as single or multifocal osteoperiostitis, and multivisceral locations in severe forms of septicemia. The disparity in this pathology between temperate countries and our own tropical Pacific area is certainly due to PVL-positive S. aureus and ethnic factors. The high prevalence of Melanesian and Polynesian patients confirms that they are at high risk of musculoskeletal infection in New Caledonia as in other Pacific countries, and it is possible that these ethnic groups are genetically susceptible to PVL-positive strains. LEVEL OF EVIDENCE: Level IV. Retrospective case series.

Fractures of the upper transthoracic cage.

We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as 'associated' fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term 'fractures of the upper transthoracic cage' is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4-T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up.

[Acute circulatory failure following a stonefish envenomation in New Caledonia: case report]. / Envenimation par poisson-pierre: une observation d'inefficacité circulatoire en Nouvelle-Calédonie.

The purpose of this report is to describe a case of severe systemic envenomation with cardiac arrest following a sting by the stonefish Synanceia verrucosa. Although the exact mechanism underlying cardiac arrest is debatable, cardiovascular toxicity of stonefish venom appears to have been involved. This case supports the life-threatening potential of this type of accident, a much-debated topic in recent years.

[Isolated fracture of the ulnar diaphysis, from plate osteosynthesis to intramedullary nailing]. / La fracture isolée de la diaphyse ulnaire, de l'ostéosynthèse par plaque à l'embrochage centro-médullaire.

PURPOSE OF THE STUDY: The authors report a study from a series of 113 adults treated by osteosynthesis in a seven year period, for an adult isolated ulnar shaft fracture by osteosynthesis. These patients were divided into two groups: 57 patients treated by open reduction and AO plate fixation (group n(o) 1), and 56 patients operated by percutaneous intramedullary nailing, according to Böhler technique, with a simple Kirschner pin suited into the medullary canal (group n(o) 2). MATERIAL AND METHODS: For this ulnar fracture, the proportion of men and women was equal, with an average age of 37 years, predominant on the left limb (61 per cent). The most common cause was direct trauma (71 per cent): Böhler's "parry fracture", followed by traffic accidents (14 per cent), and 6 per cent by falls. We never found, in this series, indirect fractures by fall on the hand palm, and never clinical or radiological objective signs for a suspected lesion of the proximal and distal joints. Both operative procedures are described, with a particular emphasis on the simplicity of the nailing technique. No immobilization, of any kind, was applied, and patients were allowed to start full movements of the wrist and elbow, immediately after surgery. RESULTS: There were no early post operative complications, but great differences in the evolution between both groups. In group n(o) 1, there was a 29.8 per cent complication rate, 47 per cent of this was considered as "major" including osteomyelitis, non union, plate breakage, screw loosening, refractures. Patients in group n(o) 2, suffered only a few "minor" complications. Functional and anatomical results were also better in group 2 with earlier return to work. DISCUSSION: Isolated fracture of the ulnar shaft in the adult is known as a problematic fracture which needs long time to unite and often ends in non union. If opinion varies between plaster or internal fixation, we have abandoned the conservative treatment for the osteosynthesis. In order to demonstrate that intramedullary nailing technique gives a "sufficient" fixation, the authors pointed out the biomechanical importance of soft tissues structure preservation. CONCLUSION: Percutaneous intramedullary nailing of isolated ulnar shaft fractures in adult, is a simple and inexpensive technique, which gives predictable bone union, without particular complication and without drawbacks of other internal fixation techniques.

[A new strategy of neonatal screening for cystic fibrosis. The association of immunoreactive trypsin and molecular biology in dried blood]. / Vers une nouvelle stratégie de dépistage néonatal de la mucoviscidose. Association du dosage de la trypsine immunoréactive et de la biologie moléculaire dans le sang séché.

Cystic fibrosis (CF) screening by means of immunoreactive trypsin (IRT) lacks specificity: only 1 out of 12 hypertrypsinemic neonates has cystic fibrosis. We propose here to analyse the KM.19 polymorphic site in the dried blood spots as an additional test in hypertrypsinemic neonates. A blind retrospective study of 114 hypertrypsinemic samples has been performed after polymerase chain reaction. Twenty-seven of 37 CF (74%) were homozygous for allele 2 (2-2) and could have been diagnosed on the 15th day of life. Fifty-five percent of the infants tested were homozygous for allele 1 (1-1), a very rare feature in CF, conferring them a probability of being normal of 99.8%. At the moment, this test could be of great help in the CF screening, even better than the search for the delta F508 mutation for which 45.9% of CF patients are homozygous.

Braquiterapia no tratamento do cancer da mama - resultados preliminares. / Braquitherapy in the treatment of breast cancer - preliminary results

Os autores apresentam 22 casos de carcinoma de mama tratados por irradiacao exclusiva, demostram sua tecnica e tecem comentarios comparativos entre o tratamento irradiante exclusivo e o cirurgico

A ultra-sonografia na avaliacao do tratamento de massas abdominais. / Ultrasonics in evaluation of treatment in abdominal tumor

Os autores apresentam sua experiencia,utilizando a ultrassonografia em 50 pacientes com tumores abdominais determinando as relacoes da massa tumoral com orgaos adjacentes. Sao apresentados os resultados obtidos com o metodo, durante e apos o tratamento, e suas correlacoes com outros exames

[Association of chemotherapy and radiotherapy in the treatment of advanced cancer of the head and neck]. / Association chimio-radiothérapique dans le traitement des cancers avancés de la téte et du cou.

At the Head and Neck and Roentgentherapy Services of Fundaçao Antonio Prudente, São Paulo, Brazil, 38 patients with advanced cancer of the oral cavity and oropharynx, were divided into two groups: the first, submmited to treatment with Bleomycin and Linear Acelerator, and the second to isolated irradiation. Both groups received 7 000 rads in 32 days, and to the association group, Bleomycin was administered in dosis of 300 mgs. The authors concluded that, that Chemo-Radiotherapic association didn't increase the survival rate.