[Foot deformities in longitudinal ectromelia of the lower limbs]. / Les anomalies du pied dans les ectromélies longitudinales des membres inférieurs.

We have studied 204 feet in 181 children with congenital limb shortening. There were 17 short femurs in 11 children in whom it was impossible to lengthen the leg. Thirteen feet were abnormal. It was necessary to adapt the foot to fit the chosen prosthesis. In 34 children it was possible to correct the length of the short femur. In 21 the feet were normal. 13 had abnormal feet associated with fibular aplasia and deformities included equinovalgus, hind foot synostosis, and deficient rays. In 72 children with congenital hypoplasia or aplasia of the fibula, 76 feet were affected. The function of the foot depends on attaining a stable position beneath the tibia. In 34 children (35 feet), the feet were in a stable position. There were 22 ball and socket ankle joints. Before carrying out leg lengthening, operation was necessary on 9 feet, and a further 13 required operation after lengthening had been carried out. In 34 children (41 feet) there was fibular aplasia. The feet lay in equinovalgus and were often narrow. Only 5 did not have a degree of synostosis. Twenty-three feet in twenty two children were operated on with early soft tissue release, tendon transfer and tibiotalar arthrodesis. This is our treatment of choice. Twenty-seven children had tibial dysplasia which affected 37 feet. The feet lay in equinovarus and in 5 there was partial diplopodia. In the absence of a tibia (19 feet) disarticulation of the knee was carried out. In 12 there was proximal shortening of the tibia which in 9 cases was treated by tibiofibular union. It was possible to retain only 2 feet in a proper position in a lengthened leg. In 30 children (33 feet) both fibular and tibial hypoplasia was present. The feet functioned well. There were 22 ball and socket ankles, 28 narrow feet and numerous synostoses. In limbs with atypical dysplasia 7 abnormal feet were noted. If it is possible to preserve or lengthen the limb it is vital that the foot is retained in a stable position beneath the tibia in order that satisfactory function be obtained. If limb lengthening is impossible, the foot must be adapted to match the prosthesis.

Desepiphysiodesis--elimination of partial premature epiphyseal closure. Experience of 17 cases.

Between 1975 and 1990, 17 growth plates have been operated on by epiphyseal bridge resection. The children were from 4 years and 10 months to 13 years and 10 months old. The etiology of partial closure was traumatic (10 times), caused by therapeutic mistakes (3 times), septic osteomyelitis (1 case), purpura fulminans (1 case), unknown (2 cases). There was always length discrepancy or deformity of bone. The regions that have been subjected to treatment were distal femur, proximal tibia, distal tibia, distal radius. Evaluation of the bone bridge was made by tomoscintigraphies and recently by MR imaging and computed tomoscintigraphy. The bone bridge size was from 2.5% to 60% of the growth plate surface; surgical technique consists of resection of bone bridge connecting epiphysis and metaphysis which is replaced by methyl metacrylate. In 16 cases simultaneous corrective osteotomy was performed. Results are poor, there were only two good results and 8 failures; seven results were medium. The failures can all be explained by mistakes in technique or indication, except one. Indications are post-traumatic narrow bridges in young children. It would be useful to know the vitality of the residual growth plate.

Osteochondritis dissecans of the humeral capitellum in children.

We studied 13 cases of osteochondritis dissecans of capitellum humeri in 12 children, 11 boys and 1 girl, aged between 10 and 15 years. We distinguished this affection from Panner's disease which affects young children and resembles Legg-Perthes-Calvé disease of the hip. Operative treatment was performed in 7 out of 13 elbows for removal of loose bodies or excision of osteochondritis in situ with cartilage damage. In other cases, functional treatment was carried out. At long-term follow-up, ranging from 2 to 13 years, clinical examination demonstrated satisfactory results in 9 cases; in 3 cases limitation of movement was related to fracture of the radial head or to delay in operative treatment for too long. Roentgenographically, changes related to growth disturbance were constantly observed; they involved the radial head, the olecranon, the trochlea and the proximal end of the ulna.

[Long-term outcome of pectus excavatum surgically treated in children]. / Le devenir à long terme du thorax en entonnoir opéré chez l'enfant.

The authors have studied the result of 34 pectus excavatum, corrected by two surgical methods, followed up between 3 and 20 years: half of cases were treated by Judet's procedure, making turn over of anterior wall chest, with 35 per cent of good result. The other cases were treated by sternochondroplasty and internal fixation, with 88 per cent of good result. Early failures related to sternal non union and to infection, occurred in 53 per cent of Judet's procedure; eight of the 13 failures were managed by sternochondroplasty (7 cases) and Judet's procedure (1 case); followed by good results. Failure at further time was related to the young age of the patients at treatment, to the deficiency of fixation and early removal of material. Consequently, durable correction at long term was obtained, when treatment was performed by sternochondroplasty procedure, over 14 years of age, when many pins were used for fixing the correction, left in place for more than one year. In such cases, we didn't observe regression of result. When small residual deformities subsisted they were often masked by the development of the muscles in man, and breast in woman, providing acceptable aspect of chest.

Congenital dislocation of the hip in Ehlers-Danlos syndrome.

Nine patients with Ehlers-Danlos syndrome (EDS) were treated for bilateral congenital dislocation of the hip (CDH). CDH was diagnosed at six months of age in two patients and at two to five years of age in the remaining seven patients. The diagnosis of EDS, based on clinical criteria, was established considerably later. One patient with multiple deformities was only observed; the remaining eight patients were initially treated by closed reduction. Due to difficulties encountered in reduction and especially in stabilization, all hips were subsequently treated surgically, with a total of 42 procedures. Avascular necrosis of the femoral head developed in five hips, four of which had been treated with closed reduction with the patients under general anesthesia. At the follow-up evaluation, six patients had reached adulthood. Clinically, satisfactory results were obtained in 12 of 16 hips but roentgenographically in only six hips. Both femoral and innominate osteotomies are necessary to achieve and maintain the reduction in EDS patients with CDH.

[Pavlik's harness in congenital hip dislocation before the first birthday]. / Le harnais de Pavlik dans la luxation congénitale de hanche avant un an.

Three hundred cases of congenital dislocation of the hip have been treated with the Pavlik harness since 1979. The reduction is obtained by progressive flexion of the thighs. The femoral head penetrates the acetabulum from bottom to top. Placing the harness and managing the treatment must be very carefully done. The explanation given to the family is essential to success. Complications are rare. Arthrography followed by reduction in traction should be considered in case of failure. The Pavlik harness is indicated under the age of 9 months.

[The so-called Klippel-Feil syndrome and its orthopedic incidences]. / Le soi-disant syndrome de Klippel-Feil et ses incidences orthopédiques.

Eighteen cases presenting Klippel-Feil syndrome were reviewed. Clinical and radiological criteria were analyzed: short neck, severe restriction of motion, and low posterior hairline which make up the classical clinical triad. Radiological abnormalities of the cervical spine included: a reduction in the number of cervical vertebrae, fused vertebral blocks (16 cases), cervical spine-bifida occulta, spinal dysraphism (12 cases). Other cervical vertebral disorders have been added which complete the original description: cervico-thoracic abnormalities (12 cases), craniocervical junction abnormalities (7 cases) and also thoraco lumbar abnormalities (5 cases). Although this syndrome is essentially descriptive, orthopaedic complications may occur: scoliosis (9 cases) of which only two had an increasing deformity and required posterior spine stabilisation; cervico-occipital instabilities (2 cases) which although rare, should be sought out with care because they can have serious consequences; Sprengel's deformities (7 cases) which did not warrant operative intervention. The Klippel-Feil syndrome, Wilderwanck syndrome, and Goldenhar syndrome are all close descriptive entities, and have limited surgical consequences.

[The Z-shaped or serpentine foot in children and adolescents]. / Pied "en Z" ou "serpentin" chez l'enfant et l'adolescent.

Serpentine foot or Z-shaped foot, definite as varus of forefoot with valgus of heel, is a deformity which is advisable to separate from metatarsus varus in children. We have studied 55 serpentine feet of 31 children aged between 6 months and 13 1/2 years, observed in 20 years. We distinguished four grades of deformities. Treatment was orthopedic in 15 times, surgical in 29, with 50% of bad result, 11 feet which haven't had any treatment were in use to indicate evolution of the adductus. However, valgus of heel is transitory and secondary to forefoot rigidity, it always regressed but growth disturbance of tarsal bone occurred making lateral deviation. We insist on early radiographic diagnosis and treatment which is orthopaedic before first year of age, then surgical when first failed or in old children. It get release of metatarsal stiffness before 6 years of age, then in older we make osteotomy of 1 degree cuneiform and cuboid to correct bone deformity. Correction of hind foot valgus, realized in 24% of the surgical treatment, must be prohibited, it always made transverse tarsal instability.

[Intervertebral disk calcification in children]. / Calcifications discales inter-vertébrales chez l'enfant.

Thirty one intervertebral space calcifications (I.S.C.) were studied in 21 children (12 boys, 9 girls), with mean age of 7 years; 25 calcifications had been followed for an average of 71.5 months. The main symptom was pain (Crisis) which relieved in a delay of 1 month in 70 per cent of cases. "Crisis" and radiographic fragmentation of the calcification are both criteria of going out of 18 calcifications, in a delay ranged from 28 days to 6 months. The calcification appears as a sign which disclose a general disease of spine, interesting vertebral body, growth plate, and disc; therefore we have observed 15 lesions due to growth disorders in 16 cervical I.S.C., at dorsal level we have described 4 cases of intrasomatic cavitation containing calcified material, opened in the intervertebral space. This growth disturbance has been noted either on first radiograph, or has appeared later, after disappearance of the I.S.C.; we found more over absence of listel and lesion of multiple plates distant from the calcification. This disease is identified to vertebral osteochondrosis where residual deformities are more worrying than the benign calcification; they have concluded management of I.S.C. as early as possible to avoid great deformities of vertebral bodies.

Surgery in residual clubfoot: one-stage medioposterior release "à la carte".

A series of 142 clubfeet in 113 children were treated by a one-stage medioposterior release for deformity persisting after vigorous physical therapy. The talonavicular joint and hindfoot are released to achieve correct alignment. Long-term good results were seen in 73% of the entire series and in 87% of the idiopathic subgroup.