Anterior screw-plate fixation in adolescent idiopathic scoliosis: 15-year outcomes.

BACKGROUND: Few published data are available on long-term outcomes of anterior spinal fusion for adolescent idiopathic scoliosis (AIS). The objective of this single-centre retrospective study was to assess clinical and radiological outcomes of one-stage anterior spinal fusion achieved using precontoured titanium anterior screw-plates. HYPOTHESIS: Our hypothesis was that anterior instrumentation produced both good functional outcomes and good correction in the coronal and sagittal planes. MATERIAL AND METHODS: This procedure was performed in 111 patients between 1975 and 1993. Among them, those who underwent a comprehensive evaluation at least 15 years later were included. The SRS-30 questionnaire and Oswestry Disability Index (ODI) were used to assess functional outcomes. Radiographic outcomes were evaluated on antero-posterior and lateral full-spine radiographs obtained pre-operatively, post-operatively, and at last follow-up. RESULTS: The study included 35 patients, who were re-evaluated after a mean of 21 years (15-31 years). Mean pre-operative Cobb's angle was 44°, mean age at surgery was 14.7 years, mean SRS-30 score was 3.65/5, and mean ODI was 14.9%. At last follow-up, mean Cobb's angle was 14.7° and 25 patients exhibited coronal misalignment with a mean deviation of 12mm. In the sagittal plane, the mean sagittal vertical axis (SVA) measured using the C7 plumb line was -28mm, with 8mm of anterior translation compared to the post-operative value (36mm). The functional outcome assessed using the SRS-30 score correlated significantly with pelvic tilt and anterior SVA translation. CONCLUSION: Anterior spinal fusion produces good long-term functional outcomes in AIS. Correction is both satisfactory and sustained. Anterior SVA translation over time may be associated with better functional outcomes. LEVEL OF EVIDENCE: IV (retrospective study).

Acromicric dysplasia: long term outcome and evidence of autosomal dominant inheritance.

Acromicric dysplasia is a rare bone dysplasia characterised by short stature, short hands and feet, normal intelligence, mild facial dysmorphism, and characteristic x ray abnormalities of the hands. Only a very small number of children with this condition have been reported so far. Here we report on a series of 22 patients including 10 boys and 12 girls with acromicric dysplasia. Length was normal at birth and height fell progressively off the centiles postnatally. The mean adult height was 130 cm (133 cm in males, 129 cm in females). The hands, feet, and limbs were short and OFC was normal. Intelligence was normal and mild dysmorphic features were noted. Other occasional features included well developed muscles, a hoarse voice, generalised joint limitation in some patients, frequent ear, tracheal, and respiratory complication, and spine abnormalities. Long term follow up showed that facial dysmorphism was less obvious in adults and that carpal tunnel syndrome was frequent in older patients. Apart from short metacarpals and phalanges, internal notch of the second metacarpal, external notch of the fifth metacarpal, and internal notch of the femoral heads, there were no major x ray abnormalities. No major complications, such as cardiac disease or major orthopaedic problems, occurred in the course of the disease. The condition appeared to be sporadic in 16 cases but the observation of vertical transmission in three families was consistent with an autosomal dominant mode of inheritance.

[Value of somatosensory evoked potentials in spinal surgery monitoring in children and adolescents: 110 cases]. / Intérêt des potentiels évoqués somesthésiques dans la surveillance de la chirurgie du rachis chez l'enfant et l'adolescent: à propos de 110 cas.

This study shows the results obtained in 110 patients, children and adolescents by monitoring somatosensory evoked potentials during spinal surgery: Cotrel-Dubousset instrumention, surgical anterior correction by plating, spondylolisthesis and hemivertebra surgery. The recordings were made in preoperative, peroperative and postoperative period; the anaesthetic and electrophysiological conditions allowed us to obtain reliable recordings. In the peroperative period, the recordings were made: after induction of anesthesia and exposure of the spine, after instrumentation, after maximum traction and at the end of the operation. Analysis of the peroperative somatosensory evoked potentials (PESEP) showed significant differences in latencies, but also in amplitudes and morphology during distraction in scoliosis or spondylolisthesis. These impairments gradually improved and recovered their normal values at the end of the operation. The impairments were, with equal correction, 4 times more important in Cotrel-Dubousset instrumentation than in surgical anterior correction by plating. During instrumentation and in two cases, the impairments observed led the surgeon to change his operative behavior, certainly avoiding a postoperative neurological disorder, the "wake-up test" was made in one case. The correlation between the neurological problems, and the impairments of the potentials allowed us to define alarm criteria, and if they persist the "wake-up test" becomes necessary.

[Monitoring of somatosensory evoked potentials during surgery for scoliosis in young adults: apropos of 33 cases]. / Surveillance per-opératoire des scolioses chez l'adulte jeune par les potentiels évoqués somesthésiques: à propos de 33 cas.

The risk of serious neurologic complications in spinal surgery for scoliosis is not insignificant. The recording of cortical somatosensory evoked potentials (CSEP) is an electrophysiological method of monitoring during surgery. Measurement of CSEPs was carried out before, during and after surgery in a preliminary series of 33 patients. These recordings were made: after induction of anesthesia and exposure of the spine; after instrumentation but without correction; after maximum traction; and at termination of surgery. The aim of this work was to establish alarm criteria. Statistical analysis showed a significant increase in latencies after instrumentation without correction, and after maximum traction. The alarm criteria were determined as an increase of more than 5 msec in the first positive deflection associated with an unusual drop in amplitude (over 75%). If these anomalies persist, the "wake-up test" must be used. In practice, this monitoring has often aided in reducing the period of surgery by using the "wake-up test" in a few selected cases.

Long-term follow-up of surgical correction of Madelung's deformity with conservation of the distal radioulnar joint in teenagers.

Eleven wrists with painful Madelung deformity in seven patients were corrected during adolescence by a closing wedge osteotomy of the radius and a shortening osteotomy of the ulna, with conservation of the distal radioulnar joint. At late follow-up (9.7 years) function was considerably improved. When the ulnar head was correctly relocated during operation, a new distal radioulnar space developed. Shortening of the ulna must be generous and combined with slight flexion at the osteotomy.

Bilateral congenital pseudarthrosis of the olecranon.

A case of bilateral congenital pseudarthrosis of the olecranon is reported in a 15-month-old boy. This abnormality was noted at birth because of a fixed flexion deformity of both elbows. The left side was operated on at the age of 16 months and the right side at 21 months. Surgical exploration showed a mobile pseudarthrosis with a 2-cm gap between the tip of the olecranon and the nucleus, each one covered with cartilage. This cartilage was excised, the triceps tendon was lengthened to allow the lowering of the nucleus, and both fragments were fixed with nylon threads. The elbow was kept extended for 30 days in a plaster cast. Fusion was obtained shortly. At the 2-year follow-up, the function was nearly normal as was the radiological appearance. This abnormality is very rarely reported in the literature, and we emphasize the necessity of an early operation.

Bone growth after lengthening of the lower limb in children.

Femoral and tibial growth was studied in 6 children undergoing a femoral lengthening and 28 children a tibial lengthening. Growth of both femurs and tibiae was evaluated for 3 years both before and after the procedure. No significant growth disturbance was noted in femoral lengthenings of 14%. However, growth variations were constant after tibial lengthening of 18% on the average and could be correlated to the amount of lengthening. The consequences of these changes are limited in terms of final limb length because overgrowth of the femur often compensates for growth retardation of the tibia when tibial lengthening is less than 18%. Experimental and clinical studies assert that lengthenings of more than 30% can result in significant and definite growth retardation of the lengthened bone.

Assessment and neurologic involvement of patients with cervical spine congenital synostosis as in Klippel-Feil syndrome: study of 19 cases.

We reviewed 19 children and adolescents with cervical spine congenital synostosis as in Klippel-Feil syndrome (KFS), with an average follow-up of 12.5 years. We paid particular attention to neurologic complications associated with cervical spine abnormalities. Five patients were affected by neurologic complications; four underwent a surgical procedure; and 14 had no neurologic finding. Two had hypermobility at one level, and one had hypermobility at two levels. We found that the more numerous the occipito-C1 abnormalities, the more significant the neurologic risk. In contrast, this risk was not related to the number of "mobile blocks" or to age. Various mechanisms of neural complications have been studied in the literature: medullary abnormality, spinal instability, narrowing of the cervical canal, and vascular dysfunction. Surgery is usually thought to be required in cases with neurologic complications. The indication for surgery is, however, less clear in cases of pure instability without neurologic involvement because surgery is likely to increase the future risks at mobile disks either above or below the fuse level. Careful clinical and radiologic observation is necessary in such patients. Magnetic resonance imaging (MRI) with lateral views in flexion and extension seem to be the best method for detecting impingement of the spine on the cord.

Obstetric dislocation of the thoracic spine: case report and review of the literature.

A fracture dislocation of the upper thoracic spine with spinal cord injury is reported in a neonate. This rare injury is associated with attendant predisposing obstetric circumstances (breech transverse presentations, large baby size) that can alert clinicians of potential problems and aid in the diagnosis of neonatal hypotonia and paralysis.

Evolution of scoliosis in six children treated with growth hormone.

During a period of 6 years to 11 years, the authors have been following six girls with scoliosis and treated with growth hormone (GH) for a growth insufficiency. The treatment with GH started after the discovery of the scoliosis for five patients. Three curve progressions have been observed, but always in the puberty period. Only one progression was noticed at the beginning of the GH treatment, but it was relieved with bracing. The results of this study do not permit one to conclude that a relation exists between GH treatment and scoliotic progression. This treatment is nevertheless not devoid of side effects, and a rigorous supervision is necessary.

[Delayed-action drainage. A device for the reduction of postoperative blood loss in surgery of the spine]. / Le drain différé. Un artifice visant à diminuer les pertes sanguines postopératoires dans la chirurgie du rachis.

A new type of surgical drain is presented. Its purpose is to avoid excessive blood loss after operations on the spine while enabling residual haematomas to be drained later on. The drain consists of a plastic tube containing a flexible mandrel of synthetic material which ensures complete and watertight obturation of the tube. Subsequently, the mandrel can be removed, living the drain in situ for aspiration. The drain is introduced as any other aspiration drain; it is obturated for 5 days and then removed after being put under a vacuum for 5 hours. This device has been used in surgical operations of the Cotrel-Dubousset type performed on the spine; it avoided major postoperative blood loss and enabled most transfusion procedures to be successfully carried out without secondary blood collections.

[Anterior spinal cord decompression in paraplegia in angular kyphosis. Apropos of 5 cases in children and adolescents]. / La décompression médullaire antérieure pour paraplégie sur cyphose angulaire. A propos de 5 cas chez l'enfant et l'adolescent.

The authors performed an anterior medullar decompression and a vertebral arthrodesis with bone grafts in 5 children and adolescents suffering neurological troubles caused by an angular kyphosis. 4 patients out of 5 completely or almost completely recovered from their paraplegia in the days or weeks following surgery. The authors stress the infrequency of the indication of such a procedure justified in either recent or incomplete neurological troubles without improvement by immobilization and rest. This procedure, which may raise technical problems, gives way to the rapid recovery of a satisfying functional state. It is to be considered in view of these dramatic situations.

[Excessively long calcaneal spur. A rudimentary form of calcaneo-navicular synostosis]. / Un bec calcanéen trop long. Une forme rudimentaire de synostose calcanéo-scaphoïdienne.

The authors have seen 5 children aged between 12 and 16 years suffering from a painful foot described as a recurrent sprain. Movements of the subtalar joint were limited and radiographs showed a hypertrophic calcaneal spur projecting towards the navicular but without fusion between the calcaneus and navicular. The calcaneal spurs were resected with good results and with an immediate symptomatic improvement.

[Old fractures of the lateral humeral condyle (lateralis capitellum humeri) in children]. / Fractures anciennes du condyle externe (lateralis capitellum humeri) chez l'enfant.

The authors report their experience of 19 cases of non recent fractures of the lateral humeral condyle in children. The delay from the initial trauma to the first clinic was: minimum, 45 days (this delay defines a non recent fracture), maximum 7 years. 18 patients sustained an operation, 15 non-unions and 3 malunions; 1 patient was not operated on. The mean follow-up was about 5 years. The authors have determined two groups of patients according to the delay of treatment, less or more than 6 months. In the first group, 13 procedures out 14 allowed fusion of the condyle without necrosis. In the second group, the severe malalignments of the elbow required a varus or a valgus osteotomy.

[Spondylolisthesis with severe displacement in children and adolescents Results of 12 cases of posterior reduction fixation]. / Spondylolisthésis à grand déplacement chez l'enfant et l'adolescent. Résultats de 12 cas de réduction-fixation postérieure.

The aim of this study was the analysis of 12 cases showing a L5-S1 spondylolisthesis of a shift superior to 50%. The surgery performed on those 12 children and teenagers was Roy Camille's technical procedure that is reduction and fixation with posterior plates and postero-lateral grafting The criteria of the study and technique used are first recalled. The result's analysis show the quality of the reduction and the restoration of the lumbo-pelvic statics. The postero-lateral arthrodesis appears to the authors as sufficient to guarantee the result's stability. In cases of associated radicular impairment, great care must be taken as far as the reduction is concerned. The root must be controlled during the surgical procedure especially if there is a real sciatic before surgery. The technic appears to the authors as the best among all those they may have used for the treatment of the spondylolisthesis with an important shift, apart from the spondyloptosis. Internal fixation devices of a smaller size would be necessary for a small child.

[Traumatic C1-C2 luxation in children. Prognostic study and therapeutic indications apropos of 13 cases]. / Luxation traumatique C1-C2 chez l'enfant. Etude pronostique et indications thérapeutiques à propos de 13 cas.

The authors reviewed the cases of 13 children with C1-C2 traumatic dislocations. A particular interest was given to the elements which seemed to have an influence on the conservative treatment. Two points are of determining importance: the type of dislocation and the delay since the trauma. Pure rotatory dislocations generally occurring after a slight trauma healed thanks to a strict and necessarily early immobilization. On the contrary anterior dislocations due to violent traumas and all C1-C2 dislocations which treatments were delayed required an arthrodesis.

[The incidence of progressive scoliosis and kyphosis after fractures and dislocations of the spine in children (author's transl)]. / Le risque de déviation rachidienne évolutive dans les fractures et luxations du rachis chez l'enfant.

The authors have observed forty-two cases of fractures and dislocations of the spine in children. In twenty-eight cases there was a complete spinal cord lesion and in four cases a partial cord lesion with some recovery. Ten children had no neurological lesion. Fifteen progressive kyphoses and twenty-two progressive scolioses were noted and analysed. The kyphotic deformities were more severe at cervical levels and seem to be aggravated by laminectomies. They were stabilised at the time of bone maturity. To prevent this deformity, the authors recommend long-term plaster cast immobilisation associated with posterior fusion. In scoliotic deformities, the authors distinguish those due to neurological involvement and those arising at the level of the fracture due to disturbance of vertebral growth. Indications for treatment are discussed in relation to the age of the patient and the level of the fracture.

[Salter's innominate osteotomy in the treatment of congenital dislocation of the hip. Apropos of 129 cases]. / L'ostéotomie innominée de Salter dans le traitement de la luxation congénitale de la hanche. A propos de 129 cas.

The authors studied a series of 129 innominate osteotomies performed for the treatment of a congenital dislocation of the hip (C.D.H.) in 109 children. This procedure was performed at an average 26 months age and its result reviewed after 6 years and 2 months in average. The innominate osteotomy was most of the time performed after the conservative treatment of the dislocation and an articular procedure was only necessary 19 times out of the 129 hips. In 14 cases, an external derotation of the femur was associated to the pelvic osteotomy. The analysis of the results showed an excellent correction of the acetabular dysplasia as much by the improvement of the femoral head as by the decrease of the obliquity angle of the acetabular roof. At the maximum follow-up, 90.3 per cent excellent and good were counted and the results in 9.7 per cent of the cases were poor. Among these 12 poor results, 9 were caused by a technical surgical fault. The femoral antetorsion decreased in a large majority of the cases. The study of the 28 cases with an over 12 years follow-up showed that good results were time proof. The authors discuss about the criteria that may indicate surgery before 3 years. Those may only be determined on the basis of some abnormalities which remain after the conservative treatment: acetabular morphology, concentricity of the articular surfaces, femoral antetorsion and social problems.

[Effects of progressive lengthening on the growth cartilage. Value of measurement of the torque]. / Retentissement de l'allongement progressif sur le cartilage de croissance. Intérêt de la mesure du couple.

The authors have studied the pressures exerted on the growth plate during 35 progressive lengthenings of the tibia. This pressure was assessed by an indirect method. The patients have been followed up for several years. There was a correlation between the pressure and the extent of growth later. The authors consider that this aspect should be carefully considered during the period of lengthening to avoid disturbance of future growth.

[External fixation in fractures of the lower limb in children]. / La fixation externe dans les fractures du membre inférieur de l'enfant.

PURPOSE OF THE STUDY: The indications, morbidity and results of the use of external fixation for fractures of the lower limbs in children is presented. MATERIAL AND METHOD: We studied 72 fractures of the lower limbs (femur: 25; tibia: 47) in 63 children over a seventeen year period. Average age at fracture was 10 yrs 6 mos. (range 4 yrs 5 mos to 14 yrs 6 mos). Forty fractures were open fractures. The indication for external fixation was decided in three different situations: 39 isolated fractures, 11 patients with multiple fractures, and 13 polytraumatized patients. Three different devices were used: Illizarov: 4, Judet: 16, Orthofix: 52. The fixators were left in place until fracture union was demonstrable. RESULTS: Final results were classed into three groups: good, good following reoperation and sequelae. Comparison of the three different series was made using Student's T test. 9 axial deviations or malrotations occurred: 6 times correction was possible with the device in place. Three cases of osteomyelitis occurred at the fracture site. 23 pin tract infections occurred (23 per cent) 5 of which were persistent and 4 required reoperation. The average healing time was different in the three groups: 4.5 mos for isolated fractures: 8.1 mos for multiple fractures and 5.7 mos for polytraumatized patients. Reoperation was required for 4 patients: 2 bone grafts, 1 decortication, 1 bone transport. Ten refractures occurred following removal of the device, 8 times in patients presenting multiple injuries. In 46 patients with a follow-up greater than 18 months, 9 presented an overgrowth between 1 and 2 cm. Following an average follow-up of 2 years 4 months, 7 patients presented sequelae, 56 had good results, 18 following reoperation. DISCUSSION: The use of external fixation remains an irreplaceable method for osteosynthesis of open fractures with severe soft tissue injuries, multiple fractures or in the polytraumatized patient. Some disadvantages such as pin tract infections and refracture following device removal should be taken into consideration before using it for the treatment of simple, isolated closed fractures of the lower limbs in children. CONCLUSION: When external fixation is chosen for treating fractures, it is preferable to use a modular device which allows axial corrections. Local pin site care is essential to prevent early infection. Early weight bearing and dynamization as soon as possible will promote callus mineralization, removal of the device must be progressive and cast protection is recommended.