Abstract: The purpose of this study was to investigate the functional effects of a structural deformation, internal rotations (IR) of the lower limbs, on upper body balance strategies used during locomotion in 5-6 year-old and 7-10 year-old children. Balance control was examined in terms of rotation around the longitudinal axis in horizontal plane (yaw) and around the sagittal axis in a frontal plane (roll). Kinematics of foot, pelvis, shoulder, and head rotations were measured with an automatic optical TV image processor and used to calculate angular dispersions and segmental stabilizations. Older children with IR showed a lower gait velocity, particularly in difficult balance conditions than typically developing (TD) children. In younger children, the effect of the local biomechanical deficit remained limited to the lower limbs and did not affect upper body coordination. By contrast, in older children with IR, the development of head stabilization in space was affected. This was demonstrated by an "en bloc" instead of an articulated mode of head-trunk unit systematically adopted by the control group. As pelvic stabilization remains the main reference frame to organize balance control in older children with IR, we conclude that the structural deformity of the legs affect and possibly delay the acquisition of the head stabilization in space strategy.
Abstract: Lower limb rotational profile in children may cause great concern to parents and relatives. In order to give parents clear information, there is a need for referential studies giving normative data of lower limb rotational profile and its normal changes expected over growth. Our aim was to collect a large clinical series of healthy children, out of a clinic, selected from a non-consulting population and to analyse Tibial Torsion and Femoral Anteversion according to age and gender. One thousand three hundred and nineteen healthy children underwent a clinical evaluation. Tibial Torsion was assessed using the method described by Staheli and Engel, whereas Femoral Anteversion was assessed using the method described by Netter. Our results showed that there was a significant difference between males and females in Femoral Anteversion, whereas there was no significant difference between the right side and the left side. Femoral Anteversion was higher in females, and was markedly correlated with age in both genders. There was no significant difference between males and females in Tibial Torsion, nor significant difference between the right side and the left side. Tibial Torsion was slightly correlated with age in both genders. Normative data were statistically defined in this work using the +/-2S.D. range. To our knowledge, there is no large and comprehensive series in the English speaking literature that gives normative data of Femoral Anteversion. Concerning Tibial Torsion, our results compared to those published in the literature.
Abstract: BACKGROUND: To examine feasibility and relevance of a multidimensional outcome assessment approach using instrumented 3-dimensional gait analysis, via the Gillette Gait Index (GGI), and a set of validated functional and health-related quality of life tools in diplegic cerebral palsy children, before introduction as a nationwide evaluation set. METHODS: A 3-year prospective government-funded multicenter study was conducted, recruiting patients during a 9-month period classified using the Gross Motor Function Classification System and the Rodda et al sagittal walking patterns. The Gross Motor Classification System Dimensions D and E, the 10-level Gillette Functional Assessment Questionnaire, the Energy Expenditure Index (EEI), the GGI out of 3D gait analysis, and health-related quality of life, assessed by self or proxy with the questionnaire "Vècu et Santè Perçu de l'Adolescent," were selected for the study. RESULTS: Cross-sectional data subset at inclusion of 160 spastic diplegic cerebral palsy patients, the largest series in our country, 6 to 18 years old (mean age, 11.0 years), are reported. The GGI correlated significantly (P < 0.001) with the Gross Motor Classification System, the Functional Assessment Questionnaire, and the EEI for all the patients, and all but one (EEI) correlated if grouped according to Gross Motor Function Classification System or Rodda. No systematic correlation was found between the quality of life scores and the other outcome tools. CONCLUSIONS: The outcome evaluation instrument set tested in our study helps to adopt common tools, to be integrated in an evidence-based practice and to compare health status and treatment outcome between countries, specifically in different linguistic environments like in European countries.
Abstract: PURPOSE OF THE STUDY: The appropriate treatment for unilateral slipping of the upper epiphysis of the femur is controversial. Prophylactic surgical treatment raises the risk of bilateralization. The procedure is often unnecessary as the natural history of epiphyseal slipping is often favorable when the displacement is minimal. We analyzed the complications of systematic prophylactic treatment in order to determine the optimal attitude. MATERIAL AND METHODS: This was a retrospective series of 62 children who underwent surgery for unilateral slipping of the superior femoral epiphysis between 1996 and 2005. Prophylactic treatment of the healthy hip was instituted systematically. The complications were noted according to Paley. We searched for factors of risk of complications, studying the bone maturity indexes, the characteristic features of the healthy femur epiphysis and the surgical technique used. RESULTS: There were seven complications, six following prophylactic treatment and one after material removal. The rate of complications reached 11.3%. Five of the complications were minor: two local infections with favorable outcome and three patients who complained of pain in the hip at mobilization, which had totally resolved at one year. One moderate complication was noted: spiral fracture of the upper femur starting from the screw head and treated with plate fixation. The outcome was favorable. There was one severe complication: osteoarthritis of the hip joint with septicemia on day 3. The outcome was unfavorable with necrosis of the femoral head, resection and use of a spacer. A total hip arthroplasty was performed at one year. DISCUSSION: Complications were globally more frequent and more severe compared to series using prophylactic screwing. The major infection complication (osteoarthritis) observed in this series has not been reported elsewhere. There was probably a center effect since we recruited all of the most complex cases in our region. We were unable to identify any factor predictive of complications. There is apparently no clear choice between systematic prophylactic treatment and careful surveillance. Prophylactic treatment in selected patients might be the key to a successful preventive approach.
Abstract: OBJECTIVES: To propose a standardized test of joint range of motion in paediatric patients with cerebral palsy, based on the opinion of a cerebral palsy specialist group (physicians, physiotherapists and surgeons) and literature review. MATERIALS AND METHODS: A Delphi process was adapted to elaborate a complete test of lower-limb-joint range of motion. During the preparation phase, a pilot committee selected a list of items compiled from literature search and personal experience. A first questionnaire was proposed to 16 experts, then six discussion meetings followed. From the results, the pilot committee prepared a second questionnaire for the experts and finalized the complete test of joint range of motion. RESULTS: The complete test includes 24 items related to goniometric measurements in supine and prone positions. Principal conditions necessary for an accurate exam are included. Further, a testing guide with visuals of the proposed exam techniques was developed. CONCLUSIONS: The standardized testing of lower-limb-joint range of motion will allow for better communication between clinicians and will facilitate the development of a database. Care should be taken in the interpretation of the joint range-of-motion test results and realized only after reliability analysis of the test, especially interobserver reliability. A further step would be to develop an outpatient booklet for cerebral palsy that shows growth and weight curves, joint range-of-motion curves and curves of the principal radiographic measurements during growth.
Abstract: OBJECTIVE: Compare the irradiation delivered in conventional radiography and digital radiography by image intensifier during a scoliosis workup. PATIENTS AND METHODS: Our prospective randomized study included 105 patients, all of whom were identified according to sociodemographic parameters as well as criteria evaluating the quality of the full front spinal x-ray at PA incidence. The entry dose at the scapula and the exit dose in interorbital, thyroid, mammary, and hypogastric projection was measured by thermoluminescent dosimeters. RESULTS: The results of 71 girls and 28 boys, aged a mean 13.8 years with a mean weight of 47 kg were analyzed. At equal image quality, the entry dose was not significantly different between the two techniques; the mean exit dose reduction was 64% during digital acquisition. This reduction involved the interorbital (162%), mammary (43%), and thyroid (309%) regions. However, this system is more irradiating in the hypogastric region (34%). CONCLUSION: The dosimetric evaluation of the different imaging techniques used to explore the entirety of the spine should be part of radiologists' quality standard used to document their work and their choices.
Abstract: In myelomeningocele, spinal deformities are responsible for major disability. Our aim was to check the predictive power for future spine deformity of a neurological classification applied at 5 years of age. We classified patients into four groups according to their neurological examination made at the age of 5 years. Groups were defined as follows: group I, L5 or below (meaning that all the patients in this group have a paralysis that at least leaves the L5 segment intact); group II, L3-L4; group III, L1-L2; group IV, T12 and above (meaning that all the patients in this group have a paralysis that reaches T11 or above). One hundred and sixty-three patients were included. The results showed that group I is a predictor for the absence of spinal deformity. Group III or IV is a predictor for spinal deformity. Group IV is a predictor of kyphosis. It was previously known that the higher the neurological level, the higher the rate of spinal deformity at maturity, but no work had given physicians a guideline to assess the spinal prognosis in myelomeningocele patients. Our work showed, on the basis of this classification made at the age of 5 years, that future spinal disorders may be expected in some patients, while no spinal deformity may be expected in some others. Thus, an appropriate therapeutic strategy and follow-up can be planned.
Abstract: The diagnosis of scoliosis is based on the association of kyphosis, vertebral rotation, and lateral deviation of the spine. The clinical examination has to be rigorous in order to rule out a potential etiology for this tridimensional deformity. The assessment of the growth, and of the progressive nature of the scoliosis, is essential before any treatment. For minor deformities, a simple clinical monitoring will be necessary. On the other hand, for moderate deformities, a non-surgical treatment with brace will be recommended. Finally, for severe deformities, the treatment will be a surgical treatment. Surgery will consist of a spinal arthrodesis.
Abstract: BACKGROUND: A single lumbar hemivertebra can be expected to cause progressive scoliosis. The aim of this study was to evaluate the results of a lumbar hemivertebra resection and short-segment fusion through a combined posterior and anterior approach. METHODS: From 1987 to 2002, a consecutive series of twenty-one patients with congenital scoliosis or kyphoscoliosis due to a lumbar hemivertebra were managed by resection of the hemivertebra through a combined posterior and anterior approach and with the use of a short anterior and posterior convex-side fusion. RESULTS: The mean age at the time of surgery was 3.3 years (range, twelve months to 10.2 years). The mean followup period was 8.6 years. There was a mean improvement of 71.4% in the segmental scoliosis curve from a mean angle of 32.9 degrees before surgery to 9.4 degrees at the time of the latest follow-up assessment, and a mean improvement of 63.9% in the global scoliosis curve from 34.1 degrees to 12.3 degrees. The mean final lordosis was within normal values. CONCLUSIONS: Excision of a lumbar hemivertebra is safe and provides stable correction when combined with a short-segment fusion. Surgery should be performed as early as possible to avert the development of severe local deformities and prevent secondary structural deformities that would require a more extensive fusion later.
Abstract: STUDY DESIGN: Retrospective review of patients records with clinical and radiographic assessment. OBJECTIVES: To evaluate the long-term result of lumbosacral hemivertebrae resection using a combined approach. SUMMARY OF BACKGROUND DATA: Lumbosacral hemivertebrae resection by a combined posterior and anterior approach have been previously described, but only one study is concerning such a large series of hemivertebrae. METHODS: From 1980 to 2001, a consecutive series of 17 congenital scolioses due to lumbosacral hemivertebrae were managed by hemivertebrae resection using a combined approach and short anterior and posterior convex fusion. RESULTS: The mean age at surgery was 4.9 years. The mean follow-up period was 7.6 years. One postoperative complication was encountered: a patient had motor deficit and recovery was incomplete. The mean segmental scoliosis curve was 27.5 degrees before surgery, 10.7 degrees after surgery, and 8.9 degrees at the latest follow-up assessment. This represents a mean improvement of 61.1% after surgery and of 67.6% at the latest follow-up. The total main scoliosis curve improved from 28.4 degrees to 12.7 degrees and 11.4 degrees , respectively. It represents a mean improvement of 55.3% and 59.9%, respectively. The mean final lordosis was within normal values. CONCLUSIONS: This procedure offers a persistent correction with a short-segment fusion. The early surgery is able to avert severe local deformities and prevent secondary structural deformities in order to avoid extensive fusions.
Abstract: We report two cases of lipoblastoma of the buttock in a 10-month-old boy and a 20-month-old girl, the first with rearrangement of chromosome 8 and the second without cytogenetic abnormality, and one case of lipoblastomatosis of a leg in a 6-month-old boy with a normal karyotype but with a rearrangement of the PLAG1 gene. Lipoblastoma and lipoblastomatosis are two different presentation of the same rare benign soft tissue mesenchymal tumour arising from fetal white fat and occurring almost exclusively in young children under 3 years. These neoplasms have no malignant potential but may recur in cases of incomplete resection. Histological diagnosis sometimes used to be difficult because of the close resemblance of the lesion with myxoïd liposarcoma. Nowadays, cytogenetic analysis may contribute to the diagnosis by showing abnormalities of the long arm of chromosome 8, leading to rearrangement of the PLAG1 gene. Actual advances in cytogenetic molecular analysis may aid in accurate diagnosis.
Abstract: STUDY DESIGN: Retrospective review of patients records with clinical and radiographic assessment. OBJECTIVE: To evaluate the long-term result of thoracolumbar hemivertebrae resection using a double approach in a single procedure. SUMMARY OF BACKGROUND DATA: Thoracolumbar hemivertebrae resection by a combined posterior and anterior approach has been previously described, but this is the largest series of hemivertebrae reported. METHODS: From 1987 to 2003, a consecutive series of 34 congenital scoliosis or kyphoscoliosis due to thoracolumbar hemivertebrae were managed by hemivertebra resection using a combined posterior and anterior approach and short anterior and posterior convex fusion in the same day/same anesthesia. RESULTS: The mean age at surgery was 3.5 years. The mean follow-up period was 6.0 years. There was a mean improvement of 69.3% in the segmental curve from a mean angle of 34.8 degrees before surgery to 10.7 degrees at the latest follow-up assessment. The global scoliosis curve improved of 33.4% from 40.4 degrees to 26.9 degrees, respectively. Trunk shift was significantly improved. The mean final kyphosis was within normal values. CONCLUSIONS: This procedure is safe and offers a persistent correction with a short segment fusion. Surgery should be performed as early as possible to avert severe local deformities and prevent secondary structural deformities in order to avoid extensive fusions.
Abstract: The objective of this study was to assess the correlation between hip flexion contracture (HFC) and the sagittal alignment of the lumbar spine in ambulatory children with myelomeningocele. Ambulatory patients with myelomeningocele are generally free of scoliosis or kyphosis. Among them, some develop increased lumbar lordosis. It is postulated that HFC and increased lumbar lordosis may be correlated. Thirty-eight patients, with a mean age of 12.7 years, were evaluated. Standing lateral spine films were obtained and the lumbar lordosis was measured using the Cobb method. HFC was measured using the Thomas test. A statistically significant correlation was found between the lumbar curve and HFC. High values of lumbar Cobb angle (hyperlordosis) were correlated with high values of HFC. These results show a correlation between HFC and increased lumbar lordosis in ambulatory myelomeningocele patients.
Abstract: PURPOSE OF THE STUDY: The aim of this work was to validate the pertinence of a radiological index (P/A) used as a predictive factor for risk of kyphosis in children with spina bifida. P/A is defined as the ratio between P, the distance between the posterior vertebral wall and the remnant of the posterior arch, over A, the distance between the anterior wall and the posterior vertebral wall, measured on the lateral view of the spine in the most dysplastic vertebra before one year of age. MATERIAL AND METHODS: The files of 163 children were reviewed. The value of the P/A ratio was measured on lateral views of the spine obtained before the age of one year. The bone level on the anteroposterior film was also noted. The presence or absence of kyphosis was determined from the lateral views obtained at ten years of age. Paired variable analysis was used to compare the mean differences in P/A at one year and at ten years in 31 patients with a bone level of L1 or higher. The exact Fisher test was used to determine the difference in the kyphosis distributions in patients with a bone level of L1 or higher between those with P/A < or = 1/2 and the others. In addition, the specificity, sensitivity, and positive predictive value of a positive test (bone level L1 or higher and P/A < or = 1/2) for development of kyphosis were calculated. Results There was no statistically significant difference in the P/A mean value before the age of one year and after ten years. The distribution of patients with kyphosis was different between patients with a bone level of L1 or higher and P/A < /2 and the other patients (p < 0.01). Considering having a bone level of L1 or higher and a P/A < or = 1/2 as a prognostic test, the specificity was 100%, the sensitivity 87.56%, and the positive predictive value 100%. Many patients with spina bifida will develop kyphosis in the course of life. This spinal deformation raises many specific problems for patient management. Use of a radiological index as presented here allows early detection of patients at risk and can also predict which patients will remain free of deformation. This allows a selection of patients who can benefit most from more regular surveillance of the spinal static and avoid unnecessary radiographic examinations in others.
Abstract: PURPOSE OF THE STUDY: The natural history of congenital scoliosis or kypho-scoliosis resulting from a hemivertebra is well documented. The spinal deformation generally worsens in children with a free or semi-segmented hemivertebra situated in the thoraco-lumbar, lumbar or lumbosacral region. MATERIAL AND METHODS: From 1982 to 1997, fifteen pediatric patients with 15 hemivertebrae causing progressive scoliosis or kypho-scolisosis underwent hemivertebral resection via a double posterior and anterior approach associated with convex fusion. Mean age at surgery was 4.4 years. The fifteen patients were reviewed at bone maturity (Risser 4 or 5) to assess outcome. RESULTS: Genitourinary tract anomalies were associated in five of the 15 patients and intrathecal anomalies in two. Mean follow-up was 12.1 years. Segmental scoliosis was 30.2 degrees preoperatively, 12.3 degrees postoperatively and 8.9 degrees at last follow-up. The values for total scoliosis were 30.5 degrees, 12.3 degrees and 12.6 degrees respectively. This was a 70.5% improvement at last follow-up for segmental scoliosis and 58.7% for total scoliosis. The real trunk imbalance improved from 31% preoperatively to 9% at last follow-up. All these differences were significant. DISCUSSION: The main objective of surgical treatment for congenital scoliosis due to hemivertebra is to prevent the development of severe deformation which would necessitate a dangerous and difficult procedure to achieve correction. Resection of the hemivertebra via a double approach is the ideal method for early correction. The procedure not only corrects the spinal deformation but also prevents later deterioration. Correction should be performed as early as possible. The result is sustained over time if there is no other associated spinal anomaly. The procedure is safe and the technique well controlled in experimented hands. Patients need to wear a corset for only six months after resection of the hemivertebra.
Abstract: PURPOSE OF THE STUDY: Resection of malignant tumors of the proximal humerus often requires dissection of the rotator cuffs and the deltoid muscle. There is no consensus on the ideal method for shoulder reconstruction. We report the functional outcome in a homogeneous series of eight patients treated by arthrodesis using a vascularized free fibular flap. MATERIAL AND METHODS: Eight patients were included in this study. All had an aggressive tumor of the upper humerus. Tumor resection was associated with a rotator cuff and deltoid muscle resection in all patients. All patients then underwent shoulder arthrodesis using a free vascularized fibular flap fixed with a plate. Clinical and radiological evaluation was available for six patients at mean 28 months. The Musculoskeletal Tumor Society function score was used to assess overall function of the upper limb. The cosmetic outcome and radiographic bone healing as well as hypertrophy of the fibular graft were noted. RESULTS: Active abduction and active flexion were 82 degrees on average. All patients could bring their hand to the mouth. Circumduction was possible but limited in amplitude. The mean function score was 26.5/30 with an excellent functional outcome in all patients. The cosmetic outcome was considered poor by all patients. Radiographically, bone healing was achieved at last follow-up in all patients but there was one case of failed fusion between the fibular graft and the scapula which required secondary iliac grafting. Mean fibular graft hypertrophy was 32.8% at last follow-up. DISCUSSION AND CONCLUSION: Two reconstruction methods have been described for patients who require tumor resection of the upper humerus: reconstruction with preservation of glenohumeral joint function and shoulder arthrodesis. Many techniques have been described for each method. It is however difficult to compare the different series reported in the literature because rotator cuff and deltoid muscle resection was not systematically performed and reconstruction methods varied between patients. An analysis of the literature shows that preservation of motion of the scapular glenoid joint can give good functional results when the rotator cuff and deltoid muscle can be preserved. If they cannot, results favor shoulder arthrodesis which provides the patient with very satisfactory upper limb function. Use of a vascularized fibular flap has provided very good arthrodesis results. The patient must however be informed of the probable poor final cosmetic result.
Abstract: Three-dimensional concepts underlie various congenital foot deformities in the midfoot. We wondered whether the first cuneiform osteotomy, usually indicated for forefoot correction, had an effect on the hindfoot. We retrospectively studied 18 patients (31 feet) with metatarsus adductus and varus who had a biplane first cuneiform osteotomy between 1994 and 2001. No patients had associated malformations or neuromuscular disease. All had persistent pain and functional complaints for at least 2 years before surgery, and all had a minimum followup of 2 years. Group A (13 feet) with forefoot adduction without hindfoot valgus had an isolated first cuneiform osteotomy. Group B (18 feet) with slight forefoot adduction, hindfoot valgus, and supination after hindfoot valgus correction had first cuneiform osteotomy and a subtalar arthrodesis. At 5 years mean followup we evaluated multiple measurements on preoperative and followup weightbearing radiographs. Complementary demographic information and clinical patient information were collected. First cuneiform osteotomy was associated with architectural changes in hindfoot bone angles. This finding suggests new surgical approaches. Level of Evidence: Therapeutic Study. Level IV (Case series). See the Guidelines for Authors for a complete description of levels of evidence.
Abstract: Indications for forearm lengthening are rare. Between 1994 and 1999, 10 forearm lengthenings were performed in seven children for functional reasons and/or esthetic discomfort. Only one of the two forearm bones was involved in the procedure in all cases. The technique consisted of a transverse osteotomy and progressive distraction after intramedullary nailing. When a bone axis correction was needed, it was performed with a substraction osteotomy in the initial osteotomy site. The distraction device was removed when bone healing was achieved. The authors noted the various complications and assessed the amount of elongation, bone healing, and potential bone axis deviation. Mean follow-up was 4.5 years. Mean elongation was 30.8 mm. Four bone grafts were needed for delayed union. No bone axis deviation was noted. An initial axial correction osteotomy allows an easier lengthening procedure. Use of an intramedullary wire avoids axis deviation. This technique can be helpful in malformative pathologies.
Abstract: A retrospective study was used to evaluate the outcome of treatment of 135 ambulatory children with cerebral palsy. Diplegic subjects were selected from the existing database at the Gillette Children's Specialty Healthcare Motion Analysis Laboratory. All subjects had undergone gait analysis before and after intervention, which included orthopaedic surgery, selective dorsal rhizotomy, or both treatments. Outcome was based on gait pathology, gait efficiency, functional walking ability, and higher-level functional skills. Gait pathology was assessed using 16 clinically relevant kinematic parameters. Gait efficiency was assessed with steady-state oxygen consumption. Walking ability and higher-level functional skills were based on patient report surveys. Improvements were seen in all outcome measures. A significant majority of subjects (79%) improved on a predominance of outcome measures; only 7% of subjects worsened. Within the restrictions of this study design, the results indicate that surgical intervention, guided by preoperative gait analysis, is effective and safe for children with cerebral palsy.
Abstract: INTRODUCTION: The current issue of paediatric emergency care is to decrease the length of stay of the child and his/her family in the emergency department while improving health care quality. Up to now, the paediatric emergency department's triage nurses of the children's Timone hospital apply two EMLA patches when they think that a blood test will be ordered by the medical doctor in order to decrease the waiting time between the clinical exam and the blood test. PURPOSE: The objective of this study was to check if this attitude allowed to efficiently select children who will actually get a blood test. MATERIAL AND METHODS: During four weeks, the triage nurses were asked to write down for each patient after the reception time whether or not a blood test would be ordered by the medical doctor after clinical exam. We compared these data to the number of blood tests actually done. RESULTS: Out of the 2758 children admitted in the emergency department during this period, 1973 nurse prediction forms were filled out. The triage nurses predicted a blood test for 253 patients. Out of these 253 patients, only 132 of them had a blood test done. The study of various studied criteria did not allow to reveal any good agreement between the nurse and the medical doctor. CONCLUSION: The literature study shows that some medical criteria allow to improve this agreement rate. The assessment of blood test necessity have to be carried on and needs further studies in order to precise the most discriminant medical criteria.
Abstract: The aim of this work was to study the potential healing of the growth plate in the case of a central desepiphysiodesis. A central defect was made in the distal femoral growth plate of thirty 3-week-old rabbits. In group A the growth plate defect was left empty as control. The defects of group B were implanted with a polymeric cylinder fixed in the metaphysis with a pin. In group C the cylinder was fixed in the epiphysis. Two months after implantation, clinical, radiologic, and histologic analyses were carried out. In group A, the mean shortening was 12.63%; it was 4.9% in group B and 1.54% in group C. Histologic analysis showed constant appearance of an epiphysiodesis after migration of the implant in the metaphysis. No regeneration of the growth plate was observed. Prevention of migration of the interpositional material is recommended to avoid recurrence of an epiphysiodesis.
Abstract: Chronic granulomatous disease is a rare immune disease related to an anomaly in phagocytes NADPH oxidase. The characteristic clinical feature is early recurrent and sometimes serious infection. We report the case of a 22-month-old child who developed multifocal osteomyelitis, an unusual inaugural manifestation of chronic granulomatous disease. Septic chronic granulomatous disease is an uncommon differential diagnosis in children who develop recurrent infections. Diagnosis is established with specific blood tests: reduction of tetrazolium nitroblue, chemoluminescence test, molecular analysis. Therapeutic management must be undertaken as early as possible in order to preserve the long-term prognosis. No curative treatment is currently available. Aggressive treatment of each infectious focus with an adapted antibiotic regimen and in certain cases surgical debridement is required in addition to long-term antibiotic prophylaxis.
Abstract: Forty-two children with nontuberculous spondylodiscitis treated between 1966 and 1997 were reviewed, and the clinical, paraclinical, and therapeutic results are presented. The study shows the difficulties of diagnosis and understanding the pathophysiology of the disease. Additional information is provided by new imaging techniques, disc aspiration, and biopsy. The mean age at treatment was 4 years 6 months. The initial clinical presentation was often misleading and the diagnosis was often delayed (42 days average). Standard radiographs and technetium bone scans were important for diagnosis and patient follow-up. Magnetic resonance imaging and needle aspiration of the disc gave an additional reliable aid in differential diagnosis and helped to guide treatment. Bacteria were isolated in 22 of the 35 samples taken (55% Staphylococcus aureus, 27% Kingella kingae; Coxiella burnetii in one sample). The functional outcome is good if treatment is properly carried out. Disc fibrosis and occasional vertebral fusion develop inevitably in the long term. According to these results, nontuberculous spondylodiscitis is truly osteomyelitis of the spine.
Abstract: PURPOSE OF THE STUDY: Hip disease can produce major pain and functional disorders in children who should benefit from total hip arthroplasty. We report our experience with total hip prostheses implanted without cement in children.MATERIAL AND METHODS: We performed 17 total hip arthroplasties in 13 children who had various conditions, mainly chronic juvenile osteoarthritis and aseptic osteonecrosis secondary to sickle cell anemia. The acetabular inserts were not cemented. All the femoral stems were custom-made using computer-assisted preoperative planning based on standard x-rays and computed tomography findings. Outcome was assessed on the basis of patient satisfaction, pain, and function. Radiographically, we assessed stem implantation, stability and integration. Results were classed with the Harris score and also with the Steinbrocker classification in order to take into account the child's overall functional handicap.RESULTS: Mean follow-up was 36.4 months. There were three cases of superficial hematoma, one case of superficial sepsis and one acetabular loosening. All patients were satisfied. Unsatisfactory function, observed in 80% of the children preoperatively, was found in only 17% postoperatively. The Harris score improved from 23.8 preoperatively to 87.7 at last follow-up. There were no cases of stem loosening and integration was achieved in 85.3% of the cases proximally in the area with hydroxyapatite surfacing.DISCUSSION: The problem with these children is to determine when total hip arthroplasty should be proposed. We retain three important indications: uncontrollable chronic pain, normal school attendance impossible, no other possibility for conservative surgery. Several studies have reported only mediocre results with cemented stems. We opted for custom-made stems without cement for three reasons: preservation of bone stock, better adaptation to bone whose quality and morphology had been remodeled by the underlying condition and repeated osteotomies which also affect the gluteus medius, and finally, better chance of success for future revisions in these active young patients.CONCLUSION: The question on whether or not total hip arthroplasty should be performed early in these children to avoid osteotomies which could alter the longevity of a future prosthesis remains open. Custom-made stems inserted without cement have provided satisfactory results in our experience. To date, follow-up is too short to compare our results with those obtained by others using cemented stems.
Abstract: PURPOSE OF THE STUDY: There are few indications for forearm lengthening in children. Several techniques have been proposed. We report our experience with progressive lengthening of the forearm in children using a unilateral axial external fixator and an improved technique consisting in initial insertion of an intramedullary guide wire. MATERIAL AND METHODS: Since 1990, we performed 14 forearm lengthenings in 9 children. Radial agenesia (5 forearms in 4 children), and hereditary multiple exostosis (3 forearms in 2 children) were the predominant causes. The ulna was involved in 9 cases and the radius in 5. Age at initiation of the lengthening procedure ranged from 4.5 to 14.8 years (mean 9.9). The lengthening technique consisted in a transverse subperiosteal osteotomy of the bone shaft then progressive distraction with a unilateral axial external fixator. When axial deviation had to be corrected, we used a subtraction osteotomy. In our last 10 cases, we inserted an intramedullary guide wire in the lengthened bone. The external fixation was left in place throughout the lengthening procedure and until complete bone healing. Serial radiographs were used to assess bone healing, the degree of lengthening achieved and any axial deviation at the end of lengthening. RESULTS: All 14 forearms were reviewed at a mean 50.6 months. Mean lengthening was 26.4 mm (range 10 - 52 mm). There were no nerve or vessel complications. In one case, reducible claw finger completely regressed after temporary interruption of the lengthening. There were 6 cases of late healing requiring a secondary bone graft. The healing index was 61.9 days per cm gained length. There were 3 cases with an axial deviation at the end of lengthening.DISCUSSION: Insertion of a guide wire in the bone being lengthened reduced the risk of late healing compared with lengthening procedures without a guide wire, avoiding axial deviation. In addition, this technique led to more rapid bone healing so the fixator could be removed earlier. We have found this method to be easier to perform on a normally axed segment. This would require an initial subtraction osteotomy for prior alignment. CONCLUSION: Forearm lengthening is a difficult procedure. Use of an intramedullary guide wire associated with an external fixation and an initial osteotomy for axial correction when needed and possibly stabilization of the wrist is an important contribution, particularly for malformed forearms.
Abstract: 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.
Abstract: PURPOSE: The study aimed to compare two successive series of procedure using first pieces of natural madreporic coral, then coralline hydroxyapatite in traumatology. The goal of this work was to evaluate long term radiological features of absorption and influencing factors. MATERIAL: Within six years, 65 pieces were used; only impaction articular fracture on the lateral tibial plateau (31) and calcaneum fractures (23) were included 21 cases completed inclusion criteria. As there were 3 secondary infections, 18 had therefore, an aseptic evolution and were included in this series. METHODS: Absorption was evaluated in five degrees according to the volume of the remaining piece on X-rays. We also took into consideration the position of the pieces and the amount of surfaces in contact with cancellous bone. RESULTS: Among the 18 pieces followed up for more than 19 months (average 40), there were 4 sequestrations (1 tibia, 3 calcaneum), all were natural madreporic coral, the others presented osteointegration. Only natural madreporic coral pieces were absorbed, but never completely and the absorption was slow (3 to 7 years) and never complete. A radiolucent line was present in 7 out of 10 pieces of madreporic coral and none around coralline hydroxyapatite. Three developed favorably. Four were sequestred. Number of surfaces in contact with cancellous bone was correlated with osteointegration. DISCUSSION: The calcium carbonate which makes up the natural madreporic coral pieces is the site of destruction by osteoclasts. The radiolucent line is the specific witness of this biochemical activity. The radiolucent line proceeds sequestrations. No substitute of coralline hydroxyapatite has presented the same sign of peripheral absorption or sequestration. Coralline hydroxyapatite could be the correct coralline material to fill cancellous defect after elevation of an articular depression. In every case, the piece of coral must be fitted in contact with the cancellous bone in the depth of the bone. Conditions of osteoconduction of madreporic coral must be reconsidered. The degree and speed of peripheral absorption must be controlled before weight bearing is allowed.
