Triple osteotomy of the pelvis for Legg-Calve-Perthes disease: a mean fifteen year follow-up.

PURPOSE: This study presents the results of a prospective consecutive cohort of patients with Legg-Calvé-Perthes disease (LCPD) operated with triple osteotomy of the pelvis (TOP) between 1989 and 2005. We attempted to determine whether the results of TOP remain stable with time and consequently lower the risk of subsequent osteoarthritis. The primary study aims were to determine the maintenance of head coverage and joint congruity, and functional outcomes of this surgery. METHODS: Forty-five patients with a mean follow-up of 15.2 years (range eight to 24) were included. RESULTS: At latest follow-up, two patients were lost to follow-up, and two required a surgical reoperation. Cumulative maintenance of head coverage and joint congruity rate for all TOP was 84.6 % (95 % CI: 82.3-90.6 %) at 15 years. Factors significantly associated with poor long-term results were the age at diagnosis and Greene index. CONCLUSION: TOP in LCPD provides satisfactory and reproducible long-term clinical results.

Surgical correction of Madelung's deformity by combined corrective radioulnar osteotomy: 14 cases with four-year minimum follow-up.

Fourteen wrists in 11 girls, mean age 13.3 years (range 9-16) at surgery, were treated for Madelung's deformity. The presenting complaint was incapacitating pain. All were treated by radial closing wedge osteotomy and ulnar shortening osteotomy. The dorsal retinaculum was also surgically repaired in six cases. At a mean follow-up of 5.1 years (range 4-8.75), we observed improved range of motion in both flexion/extension and pronation/supination and absence of pain during daily activity. Radiographically, positioning of the distal radial articular surface and lunate subsidence were improved. Union was obtained after all osteotomies without secondary procedures. Posterior displacement of the ulnar head persisted in two wrists. Combined radioulnar osteotomy restored the anatomy to as near normal as possible. This technique provides satisfactory and encouraging results and does not compromise the surgical future of the wrist. However, longer follow-up is required to assess recurrence or possible long-term degenerative consequences.

Meniscal tears in children and adolescents: results of operative treatment.

The goal of this study was to evaluate the results of meniscal repair in children and adolescents by a retrospective case series. Twelve arthroscopic-assisted meniscal repairs were performed on 12 patients younger than 17 years of age (8-16 years, mean 13 years). The anterior cruciate ligament was torn in three cases. Eight lesions involved the lateral meniscus and four involved the medial meniscus; there were no discoid menisci. All patients were seen at an average of 3 years 1 month follow-up (range, 2-4 years 10 months). Three patients required subsequent surgery for partial meniscectomy. We evaluated the remaining nine patients by clinical examination, International Knee Documentation Committee clinical score, Lyshölm score, Tegner's activity, and by computed tomography arthrogram or magnetic resonance imaging. Seven patients were asymptomatic at follow-up, two reported occasional pain, and none had experienced symptoms of locking. Their average Lyshölm score and Tegner's activity were 96.3 and 6.6, respectively. Eight patients were International Knee Documentation Committee A and one was International Knee Documentation Committee B. Healing status was assessed at follow-up in eight patients by computed tomography arthrogram or magnetic resonance imaging: the tear was considered as completely healed in three patients. The apparent failure rate was 66%. Indications for meniscal repair in children are not actually established. The pejorative outcome of meniscectomy at a young age has led us to consider symptomatic meniscal tears for repair. Objective results of meniscal healing are poor. The method to assess healing of the repaired menisci objectively is still a matter of debate.

Surgical treatment of radial neck fractures in children by intramedullary pinning.

Various surgical techniques have been used to treat displaced radial neck fractures in children, in order to reduce the displacement and to avoid complications. We report the results of a retrospective study performed on 20 patients with severely displaced radial neck fractures, who were treated with intramedullary pinning (Métaizeau technique). Mean age at injury was 9 years. Clinical and radiographic evaluation was performed. At final follow-up, there were 17 (85%) excellent or good results, 1 (5%) fair and 2 (10%) poor. Complications noted were anterior epiphysiodesis in one case and avascular necrosis of the radial head in another. Heterotopic ossification, neurovascular deficit or deep infection were noted in no instance.

["In-toeing and out-toeing"]. / "Les pieds qui tournent".

From birth to the end of growth, a femoral detorsion associated with a lateral tibial torsion can be observed. The absence or the exaggeration of this phenomenon leads to rotational abnormalities of the lower limbs called by parents as " in-toeing or out-toeing ". This represents one of the most frequent motives for consultation in pediatric orthopedics. The analysis of the respective position of knees and feet during walking and the measurements of femoral and tibial torsion allow the diagnosis of rotational abnormalities. During growth, the degree of these anomalies may increase or decrease spontaneously. As there is no evidence of a relationship between rotational abnormalities and arthritis, there are no preventive orthopaedic or surgical treatments. However, at the end of the growth, the persistence of functional symptoms leads to femoral or tibial derotation osteotomies.

Percutaneous Ethibloc injection in the treatment of primary aneurysmal bone cysts.

The effects of percutaneous Ethibloc (Ethicon/Johnson & Johnson, St-Stevens-Woluwe, Belgium) injection into primary aneurysmal bone cysts were analysed. Two patients with a venous drainage after injection of a medium contrast were excluded. Twelve patients underwent at least one percutaneous injection of Ethibloc. The average follow-up period was 5.1 years. At final follow-up, six patients had complete healing of the cyst, three had partial healing and three, who had no response, were treated by curettage and bone grafting. Complete healing was observed for all the aggressive lesions. No major complications were noted. Ethibloc injection may be performed as a primary treatment of aneurysmal bone cysts if the technique is followed with precision.

Integra artificial skin in the management of severe tissue defects, including bone exposure, in injured children.

A dermal substitute, Integra (Integra Neurosciences Implants SA, Sophia Antipolis, France) artificial skin, was used for wound management on three children with lower limb injuries in our institutions. In one case this biosynthetic material was applied directly to a bony surface (patella). This technique allows an early wound coverage and provides a satisfactory preparation for autograft. It can be a useful adjunct in the treatment of severe tissue defects in child limb injuries.

Distal fibular reconstruction with pedicled vascularized fibular head graft: a case report.

We present an original technique for reconstruction of the distal fibula after tumor resection. The case report was of a 13-year old boy suffering from an osteogenic sarcoma of the distal fibula. Pedicled vascularized epiphyseal transfer using the ipsilateral proximal fibula was performed. Results were assessed at 2 years and 6 months and provided good stability and normal functional outcome of the ankle.

Osteoid osteoma of the elbow in children: a report of three cases and a review of the literature.

Although osteoid osteoma is a relatively common lesion, it is rarely found at the elbow. We report three cases of osteoid osteoma of the olecranon fossa in patients under the age of 15 years. Diagnosis was delayed because of nonspecific clinical and radiological features. The three patients suffered from synovitis due to flexion contracture while at the same time prosupination remained normal. Only one patient complained of specific nocturnal pain. All cases had a latency between the onset of symptoms and the appearance of radiological signs. Open surgical excision of the nidus resulted in relief of pain in all cases and motion recovery in two cases. Diagnostic difficulties and treatment options are discussed.

Assessment of the position of the navicular by three-dimensional magnetic resonance imaging in infant foot deformities.

As the navicular is unossified in infants with foot deformities, until 5 years old (boys) and 3 years old (girls), it is difficult to give the exact position of hindfoot bones. Magnetic resonance imaging associated with three-dimensional reconstruction allows the visualization of the cartilaginous volume of the bones and the measurement of the relationships of the navicular with the talus. In normal feet, we noted that in the coronal plane the navicular was laterally situated (75%) relative to the talus. In club feet (17 patients), the navicular and the cuboid had a large medial displacement (77%) with a slight pronation movement in the sagittal plane. In suspected skewfoot (seven feet) we noted three cases with a lateral subluxation of the navicular. This objective technique of measurement may be of value for diagnosis and treatment of foot deformities.

Congenital pseudarthrosis of the clavicle: a histopathological study in five patients.

Congenital pseudarthrosis of the clavicle is usually situated on the right clavicle. Pathological data on pseudarthrosis are scant. The histological analysis of five cases treated by 'en bloc' surgical resection are reported. Enchondral ossification was observed on both sides of the resected pseudarthrosis in two cases. Less characteristic enchondral features were noted in three cases. These findings confirm that the pseudarthrosis is due to the failure of coalescence of the two primary ossification centers of the clavicle.

Simple bone cysts of the proximal humerus complicated with growth arrest.

A simple bone cyst of the proximal humeral metaphysis was found to cause growth disturbance with shortening and deformity in four patients. All had one pathological fracture. Three of them were treated with cortisone injections; the fourth patient, who presented an erosion of the physis, was treated with saline solution irrigation. Four hypotheses about the aetiology of growth arrest in the evolution of this benign lesion, are discussed: iatrogenic lesion of the physis, growth plate involvement by fracture, cortisone injection, and increased cyst pressure leading to erosion and even perforation of the growth plate.

A subscapularis-preserving arthroscopic release of capsule in the treatment of internal rotation contracture of shoulder in Erb's palsy (SPARC procedure).

The purpose of this study was to evaluate a minimally invasive subscapularis-preserving arthroscopic release of capsule in the treatment of internal rotation contracture of the shoulder due to Erb's palsy. We performed our procedure (subscapularis-preserving arthroscopic release of capsule) in 10 paediatric shoulders with an average age of 20.2 months and followed them for an average period of 41.5 months. All the patients were assessed clinically and radiologically preoperatively and postoperatively at regular intervals. The Mallet scoring system was used for analysing the results. The average gain in passive external rotation was 50°. The active internal rotation was preserved in all the cases. With the mid-term follow-up, there was no loss of the gained external rotation or the recurrence of internal rotation contracture of the shoulder. Our hypothesis has achieved its goal in preserving subscapularis, active internal rotation and treatment of internal rotation contracture of the shoulder. The success of this procedure lies in the early identification of starting of internal rotation contracture and early surgical intervention to prevent progressive permanent glenohumeral osseocartilaginous deformity.

Arthroscopic release for shoulder internal rotation contracture secondary to brachial plexus birth palsy: clinical and magnetic resonance imaging results on glenohumeral dysplasia.

Internal rotation contracture of the shoulder in brachial plexus birth palsy frequently leads to shoulder dysplasia. Six children underwent anterior arthroscopic release sparing the subscapularis. Clinical examination and MRI were performed preoperatively and repeated at the 5-year follow-up. MRI was carried out for assessment of glenohumeral dysplasia. Passive external rotation was improved by 63.3° without any limitation of active internal rotation. Active antepulsion/abduction was improved by 90°. Remodeling of the glenoid and improved coverage of the humeral head were observed in all cases. Shoulder arthroscopic release sparing the subscapularis seems to be an efficient procedure to restore external rotation without affecting active internal rotation.

Peritraumatic reactions and posttraumatic stress symptoms in school-aged children victims of road traffic accident.

OBJECTIVE: The purpose of this study is to investigate the power of self-reported peritraumatic distress and dissociation to predict the development of posttraumatic stress disorder (PTSD) symptoms in school-aged children. METHODS: School-aged children aged 8 to 15 years admitted to an emergency department after a road traffic accident were enrolled (n=103). Participants were assessed with the child versions of the Peritraumatic Distress Inventory and the Peritraumatic Dissociative Experiences Questionnaire within 1 week. Posttraumatic stress disorder symptoms were then assessed at 5 weeks. RESULTS: A significant association between peritraumatic variables and two measures of PTSD symptoms was demonstrated. However, in a multivariate analysis, peritraumatic distress was the only significant predictor of acute PTSD symptoms (beta=.33, p<.05). CONCLUSIONS: As has been found in adults, peritraumatic distress is a robust predictor of who will develop PTSD symptoms among school-aged children.

Ulnar styloid fracture in children: a retrospective study of 46 cases.

Ulnar styloid fractures are frequently ignored in the treatment of wrist fractures in children. Forty-six untreated ulnar styloid fractures (40 tip and six base fractures) associated with radial injuries (45 patients) were retrospectively analysed. At the removal of the cast, we recorded that 80% had a nonunion of the styloid fracture. Thirty-five patients were reviewed at an average of 19 months after treatment. Thirty tip fractures and five base avulsions were found. We recorded 28 patients with a good clinical result despite 21 cases of nonunion, whereas seven patients (all nonunions) had a fair result. All the fair results suffered from intermittent pain during sports and movement, radioulnar joint instability and tears of the triangular fibrocartilage complex. It can be concluded that both distal radius and ulnar styloid fractures should be taken into account in the initial treatment and pain associated with a nonunion of the ulnar styloid in a child may be due to a tear of the triangular fibrocartilage complex.

Classification of chance fracture in children using magnetic resonance imaging.

STUDY DESIGN: MRI study of pediatric Chance fracture. OBJECTIVE: To evaluate bone and soft tissue lesions in pediatric Chance fracture. SUMMARY OF BACKGROUND DATA: Several descriptions and classifications have been already developed for Chance fracture, but mainly for adult. Furthermore, they are all based only on radiographic studies. METHODS: MRI and radiographs of 18 children with Chance fracture were analyzed before treatment. RESULTS: On MRI, in all cases, no abnormal signs were noted on the intervertebral disc. Six patients had a bone fracture going through the pedicle and the vertebral body. Twelve patients had a physeal injury located on the superior or on the inferior vertebral endplate. Three types of lesions could be identified according to the location of the lesion in relation to the pedicle. CONCLUSION: MRI is useful in the diagnosis of pediatric Chance fracture. It allows physeal injury to be clearly identified from disc injury.

Spinal cord monitoring in scoliosis surgery using an epidural electrode. Results of a prospective, consecutive series of 191 cases.

STUDY DESIGN: Retrospective analysis of a prospectively accrued series of 191 consecutive patients who underwent intraoperative neurophysiologic monitoring during scoliosis corrective surgery. OBJECTIVES: To compare the monitoring outcome of idiopathic and neuromuscular scoliosis. To demonstrate the usefulness of the epidural electrode. To report sensitivity and specificity of the monitoring method employed at a single institution. SUMMARY OF BACKGROUND DATA: Reports in the literature emphasized the difficulty to obtain data in neuromuscular patients. Multimodality spinal cord monitoring has been recommended. Despite their still debated composition, neurogenic motor-evoked potentials have proven their validity in clinical practice. METHODS: Somatosensory and neurogenic evoked potentials were attempted in all patients presenting for scoliosis correction between 1999 and 2005. Study patients were divided into 3 groups: group 1, idiopathic; group 2, neuromuscular; and group 3, miscellaneous origins. RESULTS: The use of the epidural electrode demonstrated significant usefulness in the ability of monitoring otherwise nonmonitored patients, especially in group 2. Inability to obtain any evoked potentials occurred in 4 cases (2.1%). Five cases were found to be true positives. An adapted and rapid intervention permitted to avoid new postoperative deficit in all cases. There was no instance of false-negative data. The overall method sensitivity was 100%, and specificity was 52.69%. CONCLUSIONS: The use of a single epidural electrode allowing somatosensory evoked potentials recording and spinal cord stimulation alternately is a safe and valid method of intraoperative monitoring.

Prenatal sonographic diagnosis of the congenital dislocated spine: a case report.

STUDY DESIGN: A case of congenital dislocated spine diagnosed by prenatal sonography is reported. OBJECTIVES: To report the first documented case of prenatal diagnosis, to point out the characteristic features of prenatal sonography of congenital dislocation of the spine, and to show the results of a careful management of birth in cases of congenital dislocated spine. SUMMARY OF BACKGROUND DATA: The congenital dislocated spine consists of an anterior defect in formation of the vertebrae with a displaced vertebra and angulation of the neural canal. Instability and the consequent possibility of neurologic damage are the major features of this rare entity. Early intervention is essential to prevent an irreparable neurologic deficit. METHODS: Pre- and postnatal imaging was reviewed. Early postnatal treatment is described. RESULTS: Prenatal diagnosis of the congenital dislocated spine can be detected with sonography and confirmed by radiography and magnetic resonance imaging. CONCLUSIONS: Prenatal diagnosis of the congenital dislocated spine is of the utmost importance for parental counseling and obstetrical management.