Free vascularised fibular graft for reconstruction of defects of the lower limb after resection of tumour.

We describe a retrospective review of 38 cases of reconstruction following resection of the metaphysiodiaphysis of the lower limb for malignant bone tumours using free vascularised fibular grafts. The mean follow-up was for 7.6 years (0.4 to 18.4). The mean Musculoskeletal Tumor Society score was 27.2 (20 to 30). The score was significantly higher when the graft was carried out in a one-stage procedure after resection of the tumour rather than in two stages. Bony union was achieved in 89% of the cases. The overall mean time to union was 1.7 years (0.2 to 10.3). Free vascularised fibular transfer is a major operation with frequent, but preventable, complications which allows salvage of the limb with satisfactory functional results.

Biomechanical behaviour in vitro of the spine and lumbosacral junction.

Six fresh human specimens extending from the 9th thoracic vertebra (T9) to the pelvis were used to study the biomechanical behaviour of the long lumbopelvic segments, including mobility of the sacrum. The loads were applied at T9 using pure couples up to 5 Nm. The displacements were measured by an optoelectronic method (VICON 140). Stress-displacement curves were obtained for the three angular components of the vertebra studied according to the plane of the principal stresses and of the two other planes corresponding to the coupled mobilities. Mobility decreased from T9 to the sacrum. There was mobility of the sacrum in relation to the pelvis in flexion, with a mean of 1.28 degrees (0.5 to 2.8 degrees); 3 sacrums showed a mobility of the order of one degree for torsional stresses. There was no sacral mobility during stresses in lateral flexion. The use of this experimental protocol with low mechanical stresses should allow the evaluation of long osteosyntheses extending to the sacrum.

Intraoperative optoelectronic analysis of three-dimensional vertebral displacement after Cotrel-Dubousset rod rotation. A preliminary report.

STUDY DESIGN: This study analyzed intraoperatively the three-dimensional displacement of vertebrae during rotation of the Cotrel-Dubousset rod for scoliosis correction, using an optoelectronic method. OBJECTIVE: To evaluate three-dimensional transitions and rotations of instrumented and uninstrumented vertebrae, produced by the Cotrel-Dubousset instrumentation "derotation" maneuver. SUMMARY OF BACKGROUND DATA: Published reports indicate that Cotrel-Dubousset instrumentation has been more effective in producing spinal derotation than vertebral axial derotation, but no study analyzed intraoperatively the effects on the vertebrae produced solely by rotation of the rod. METHODS: Eight patients with idiopathic scoliosis treated with Cotrel-Dubousset instrumentation underwent intraoperative optoelectronic monitoring using infrared cameras (Vicon). Markers were implanted in the spinous processes of the lower and upper instrumented vertebrae (LIV, UIV), the adjacent uninstrumented vertebrae below and above (-LIV, +UIV), and the apical vertebra. During rod rotation, acquisition and processing of cameras data were performed to obtain three-dimensional displacements of vertebrae. RESULTS: Translations and rotations of LIV and UIV were in identical directions to those of -LIV and +UIV, respectively. Orientation of the LIV hook influenced the displacement of LIV and -LIV. Posterior translation of the apical vertebra was commonly observed in thoracic King II, III, or V curvatures (apical vertebra = T9), and anterior translation in King I and IV and thoracolumbar curvatures (apical vertebra = T11-T12). Axial rotation of the apical vertebra was increased in thoracic curvatures and decreased in thoracolumbar and lumbar curvatures. Lateral translation was the major displacement observed. CONCLUSIONS: Rotation of the rod produces rotational and translational changes along each axis. These results are preliminary, but substantial. Technical improvement would allow more accurate results in the near future.

Iliosacral screw fixation for pelvic obliquity in neuromuscular scoliosis. A long-term follow-up study.

STUDY DESIGN: This was a retrospective review of a consecutive series of patients with neuromuscular spinal deformity who underwent posterior fusion and pelvic fixation using a long construct and an iliosacral screw. OBJECTIVES: To evaluate the risks and benefits of iliosacral screw fixation. SUMMARY OF BACKGROUND DATA: Neuromuscular scoliosis with pelvic obliquity poses one of the most challenging instrumentation problems, mainly because of the poor bone quality frequently found within the sacrum. Complications include failure of instrumentation, loss of sacral fixation, loss of lumbar lordosis, and a high rate of nonunion. METHODS: One hundred fifty-four patients with neuromuscular scoliosis and pelvic obliquity underwent posterior arthrodesis with pelvic fixation using an iliosacral screw. Anteroposterior scoliosis Cobb angle, frontal pelvic obliquity, and sacral inclination angle were measured before surgery, immediately after surgery, and at the 5-year and 3-month follow-up examination. Influence of etiology, severity of deformity, and associated anterior release at the scoliotic curve above also were assessed. RESULTS: Correction of scoliosis Cobb angle ranged from 53% to 70%, and loss of correction ranged from 3% to 14% at the last follow-up examination. Correction of pelvic obliquity ranged from 60% to 84%, and loss of correction was mild. Sacral inclination angle approached normal values in all patients, except for those with myelomeningocele who had preoperative pelvic retroversion. Loss of correction ranged from 0.3 degree to 5.4 degrees at the last follow-up examination. Complications and loss of correction mostly were encountered in patients with myelomeningocele and spinal muscular atrophy. CONCLUSIONS: Iliosacral screw fixation in neuromuscular scoliosis is technically standardized and easy and offers mechanically efficient and stable fixation.

Chiari I malformation associated with syringomyelia and scoliosis.

STUDY DESIGN: A retrospective review of a series of 12 children who underwent suboccipital foraminotomy and duroplasty for Chiari I malformation. OBJECTIVE: To assess the effects of this surgery on associated syringomyelia and scoliosis. SUMMARY OF BACKGROUND DATA: Suboccipital foraminotomy for the treatment of syringomyelia associated with Chiari I malformation was greatly stimulated by Gardner's hydrodynamic theory, and its results proved to be encouraging. However, several authors reported improvement or stabilization of associated scoliosis after this surgery. METHODS: A retrospective review was conducted on 12 patients who underwent suboccipital foraminotomy for Chiari I malformation associated with syringomyelia. Neurologic Impairment, extent of syringomyelia, and severity of associated spinal deformity were assessed preoperatively and at a 4.5-year average follow-up (range, 2.1-12 years). Anomaly of superficial abdominal reflexes was found in all cases, and para or tetraparesis in three cases. Syringomyelia was of variable localization and extent. Scoliosis was present in 7 cases (greater than 40 degrees in 5 cases). RESULTS: Diminution or complete disappearance of syringomyelia was observed in 11 cases, 3 months to 1 year after surgery. Superficial abdominal reflexes anomaly improved in four cases. Minimal neurologic deficit persisted in one case. Scoliosis improved in one case, remained unchanged in one case, and progressed in the five cases with preoperative severe deformity, requiring instrumentation and fusion. CONCLUSIONS: Improvement of syringomyelia and neurologic deficit, observed with suboccipital foraminotomy, supports the theory that abnormal hydrodynamics of the cerebral spinal fluid is most likely to cause these deficits.

[The place of traction and the anterior approach in the surgical treatment of kyphosis and kyphoscoliosis in children using C.D. instrumentation]. / Place de la traction et du temps antérieur dans le traitement chirurgical des cyphoses et cypho-scolioses avec l'instrumentation "C. D." chez l'enfant.

The surgical treatment of kyphosis and kyphoscoliosis in children or adolescents using the Cotrel-Dubousset (C. D.) instrument through a posterior approach may often need a further anterior procedure either before or after. We have reviewed 20 adolescents who were operated on at l'Hôpital Saint Vincent de Paul since 1983. Our choice of management was determined by consideration of the aetiology, the age, the degree of angulation and the suppleness of the kyphotic spine in hyperextension on the operating table. The use of preoperative traction for a mean of 25 days gained an improvement of 14% of the final correction. It was used in the curves which were most pronounced, usually high thoracic curves which lacked suppleness in the lumbar spine and which were stiff on the table. The anterior approach was not indicated in long double dorso-lumbar curves, usually of idiopathic origin, which had already reached an advanced stage of development. It was necessary in severe angular kyphoses which were unstable or had marked anterior stiffness. It was sometimes used in younger patients with kyphoscoliosis in which it was difficult to assess the state of maturity. After operation the kyphosis was corrected by up to 73% in simply kyphoses, 66% in kyphoscoliosis and 59% in scolio-kyphosis. After operation we were usually able to mobilise patients without a corset.

Prevention of the crankshaft phenomenon with anterior spinal epiphysiodesis in surgical treatment of severe scoliosis of the younger patient.

The aim of this study was to determine whether an anterior approach to the spine with a fusion of the growth centers of the anterior column of the spine, simultaneous by with a posterior fusion and instrumentation of the spine, in young patients with severe scoliosis who have considerable remaining growth, leads to prevention of the crankshaft phenomenon. Twelve patients who have had anterior fusion of the spine associated with posterior fusion and instrumentation of the spine were studied. In 10 of them, growth progression was demonstrated by modification of the Risser sign; for these patients no important progression of the spinal deformity was noted. One patient had no progression of the Risser sign and no progression of spinal deformity. One patient had progression of spinal deformity due to the disruption of the sacral anchorage of instrumentation. We think that this procedure leads to the prevention of the crankshaft phenomenon, and we recommend this procedure in young patients with severe scoliosis and considerable remaining growth. It must include all intervertebral levels of the rigid segment of the curve.

The use of massive bone allografts for intercalary reconstruction and arthrodeses after tumor resection. A multicentric European study.

A multicentric study was conducted by the European Musculoskeletal Oncology Society on 113 cases of resection for tumors of the major long bones and reconstruction with massive allografts, as intercalary diaphyseal or for arthrodesis. The follow-up was at least 12 months. There was a 14% incidence of infection, with a higher frequency (18.5%) in intercalary grafts as compared to arthrodeses (7%). Fracture of the graft occurred in 15.5% of the cases with a prevalence in the humerus (28.5%) as compared to the tibia (21.4%) and femur (14.7%). Fracture constantly occurred after osteosynthesis with screws, in 16% of the cases after osteosynthesis with a plate, and in 12.5% of the cases after osteosynthesis with an intramedullary nail. It was observed in 32% of the grafts preserved at -30 degrees, in 17% of those irradiated, and in 7% and 7.6% of those preserved at -180 degrees and -80 degrees, respectively. Delayed union and non-union was observed in 57% of the cases: 63% in intercalary grafts, 48% in arthrodeses. Final results after treatment of complications were excellent and good in 63% of the entire series. The results should, however, be evaluated after 3 years, as during this period of time important transformation phenomena of the graft occur. Complications are observed in 75% of the cases, but they may be reduced if planning is correct and surgery is accurate. Each complication may be dealt with and resolved without high risks for preservation of the limb.

[Failure of Dwyer's procedure in internal pes cavus in children. Physiopathological considerations and therapeutic deductions]. / Les échecs de l'opération de Dwyer dans le pied creux interne de l'enfant. Considérations physiopathologiques et déductions thérapeutiques.

The authors have performed 34 Dwyer's calcaneal osteotomies in children with pes cavus confined to the medial arch in non-paralytic lesions (poliomyelitis and spina bifida were excluded). In 12 cases it was associated with osteotomy of the 1st metatarsal or with plantar release. No arthrodeses were performed in these 34 cases. After an average follow-up of five years the results were doubtful: in 24 instances the deformity was the same or worse. In 21 cases a secondary operation was necessary. The authors considered that the Dwyer's procedure corrects only the varus of the heel which is a secondary deformity. They believe that, in pes cavus, there is a dynamic clawing of the toes in the swing phase of gait. This produces secondary deformities. In the sagittal plane there is a synergic or paralytic imbalance at the metatarso-phalangeal level leading to vertical displacement of the 1st metatarsal and deepening of the medial arch. In the frontal plane, this vertical displacement leads to an irreducible pronation of the forefoot with secondary varus of the heel. In the horizontal plane a lateral rotation of the talus results in varus of the calcaneum.

[Fibrous dysplasia of long bones with remission. Apropos of 3 cases]. / L'ostéofibrodysplasie des os longs à évolution régressive. A propos de 3 observations.

Three cases of fibrous dysplasia of bone, affecting the long bones of the leg are described. This condition is a clearly defined radiological and clinical entity. The tibial lesion is reminiscent of a congenital pseudarthrosis but the involvement of the fibula is a useful diagnostic clue. The most important feature of the condition is that it heals spontaneously.

[Attitude of the paralytic supination of the forearm in children. Surgical treatment in 19 cases]. / Attitude en supination de I'anant-bras d'origine paralytique chez I'enfant. Traitement chirurgical à propos de 19 cas.

Nineteen cases of paralytic supination contracture have been surgically treated in children and teenagers. Three successive stages are described - 1) reducible deformity 2) contractures of soft tissues and 3) skeletal deformities. Surgical treatment aimed to improve the patient cosmetically and functionally. Ideally, the condition should be corrected early, during the first stage. The results of the Zancolli procedure of section of the interosseous membrane and rerouteing of the biceps in 11 cases were all satisfactory. Osteotomy of one or both bones could be used in association in cases with fixed deformity.