[Management of 103 limb reduction defects: a French-speaking fetal medicine club enquiry]. / Prise en charge de 103 anomalies réductionnelles de membre: une étude du Club Francophone de Médecine Foetale.

OBJECTIVES: Prenatal diagnosis of a limb reduction defect poses difficult medical and ethical problems. Prenatal diagnosis can be at the origin of two opposing medical attitudes, either a medical termination of pregnancy, or the specific management of the child at birth. The objective is to carry out an enquiry of practices and to determine whether there is a threshold in the gravity of the malformation from which the medical termination of pregnancy is accepted. MATERIAL AND METHOD: The study was carried out by a questionnaire addressed to the members of the French-speaking Club of Fetal Medicine. RESULTS: Outcome of 103 fetuses with limb reduction defect was described. Prenatal diagnosis and management of observed malformations were explained. CONCLUSION: Decisions concerning the outcome of the pregnancy are very variable from one couple to another and from one medical team to another. Parents making a request must be given complete information and accompanying psychological support. Collegial with a multidisciplinary team is necessary. For the parents, it is the physician's duty to avoid judgement errors related to anxiety and ignorance of the medical consequences. The physician should guide the parents towards the continuation of the pregnancy or its interruption. The proper decision proceeds from the reunion of the confidence of the couple and the conscience of the physician.

[Orthopedic surgery in adults with low intellectual quotients]. / La chirurgie orthopédique des adultes à quotient intellectuel bas.

PURPOSE OF THE STUDY: The object of this study was to define the requirements for successful management of polyhandicapped adults with low mental level. The goal of surgery was to improve motion performances, suppress pain, improve sitting position, and facilitate handicapped adults life. MATERIAL: Thirty-five adults operated during a period of 20 years with a follow-up between 6 months and 20 years were studied. Three of them died within 2 months postoperatively due to causes unrelated to surgery. METHOD: Surgical procedures performed were adductor tenotomies, femoral or pelvic osteotomies, femoral resections, triple arthrodeses of the foot, spine arthrodesis, lengthening of Achilles tendon, and 2 cases of femoral fractures. RESULTS: The functional goal was achieved in all cases. In 3 cases, we observed postoperative psychic regression. DISCUSSION: The surgeon must make every effort to achieve successful outcome in such cases without creating or exacerbating a behavioral impairment. Team discussions, choice of operative procedures, quality of resuscitation, and rapid return to usual life were the main factors required for successful outcome. CONCLUSION: Functional results obtained regularly in this series justifies using surgery in such cases. Cost is lower, patient's quality of life is improved, the handicapped adults relationships with others are better, and caretaker's tasks are facilitated.

[First consultation with specialists for a child presenting with forelimb unilateral agenesis. Group for the Study and Research of Limb Agenesis (GERAM)]. / La première consultation spécialisée d'un enfant présentant une agénésie unilatérale d'avant-bras. Groupe d'études et de recherche sur les agénésies de membres (GERAM).

After the birth of a child with a forelimb unilateral agenesis, the first consultation is of cardinal importance for the family. It should take place as soon as possible. The major point to be emphasized is that the child, although different, must not be considered as handicapped. If the aesthetic prejudice is evident, the functional incapacity is limited to some specific situations. In practice, the child with or without a prosthesis will have the same autonomy as children of the same age. A first prosthesis is usually proposed at 6 or 7 months of age. The child will wear the prosthesis more or less easily depending mainly upon the family attitude. It is recommended that the family have access to a medical team including a psychologist and an occupational therapist.

[Apophysitis of the iliac crest. A little known cause of low back pain and pelvic pain in children]. / L'apophysite de la crête iliaque: une cause méconnue de lombalgie et de douleurs du bassin chez l'enfant.

The authors describe an iliac osteochondrosis in 98 teenagers aged of 12 to 17 years, responsible for anterior, medial or posterior pains of pelvis and the lumbar zone, squaring with the period of ossification of the iliac crest. The spontaneous pain was revived by pressing a precise zone of the iliac crest. These pains have the usual characteristics of the pains of ossification of apophysis. The identification of the characteristics allows to avoid any further investigation which will have to be realised in case of doubt or modification of the evoluting symtomatology. It is to recognize this cause of pain so as not to attribute it to a regional morphological anomaly that may lead to excessive surgical indications. The evolution was constantly favourable after a few weeks delay. Only a momentary and adapted restriction of sporting activities is justified.

[Unilateral tibia vara in young children caused by focal fibrocartilaginous dysplasia. Apropos of 4 new cases]. / Tibia vara unilatéral du petit enfant par dysplasie fibrocartilagineuse focale. 4 nouveaux cas.

The authors report 4 cases of tibia vara associated with focal fibrocartilaginous dysplasia observed in 3 boys and 1 girl between the ages of 11 and 17 months. Deformation was usually discovered when the child began to walk. It can worsen during the first years of life, thus explaining that two subjects were operated at 3 years and at 4 years and 8 months, with osteotomy for valgus rotation. The outcome was good. The other 2 recovered spontaneously. The authors discuss the diagnostic and pathophysiological problems in the light of the data in the literature and confirm that correction is usually spontaneous, which justifies refraining from treatment.

[Supramalleolar derotation osteotomy for torsion of the leg in children and adolescents. Techniques and results: apropos of 22 patients (32 legs)]. / L'ostéotomie supra-malléolaire de dérotation du squelette jambier chez l'enfant et l'adolescent. Techniques et résultats: à propos de vingt-deux patients (32 jambes).

We have performed 32 supramalleolar osteotomies described by Mc Nicol to correct excessive internal or external tibial torsion in 22 patients (aged from 4 to 8 years, with different indications, with a follow-up of 16 months to 7 years). The consolidation of the osteotomy was obtained in 6 weeks. Eighteen patients (27 osteotomy) have a good result, 2 results are fair and 2 patients have a poor result. The indications for correction of excessive internal or external tibial torsion are very uncommon, and reserved to cases with functional disorbility of fitting appliances, or unaesthetic or uncomfortable gait.

[Quintus varus supraductus. Results of the surgical treatment by cutaneous graft, internal capsulotomy and external transfer of the extensor of the 5th toe]. / Le quintus varus supraductus. Résultats du traitement chirurgical par plastie cutanée, capsulotomie interne et transfert externe de l'extenseur du 5e orteil.

The overlapping fifth toe has often a congenital origin. It may be isolated or associated with an another pathology, congenital or acquired, but the relationship between them. Cannot be ascertained. The overlapping fifth toe is responsible for an esthetic deficit and/or a functional discomfort, it justifies a correct surgery. Twenty-one feet in 16 patients aged from 2 to 30 years (especially between 5 and 15 years) have been operated on and reviewed after a mean follow-up of 4 years. The technic associated a cutaneous dorsal Z-plasty on the cutaneous retraction a medial and dorsal capsulotomy of the metatarso-phalangeal joint, an external transfer of the fifth extensor tendon or its tenotomy and, in 10 cases, a plantar skin resection 19 results were excellent, one fair result and one failure. The condition of a stable result seems to be based on a complete and spontaneous correction of the deformity at the end of the operation.

[Tendon surgery in equinovarus deformity of the foot in children and adolescents with cerebral palsy]. / La chirurgie tendineuse du pied varus équin de l'enfant et de l'adolescent infirme moteur d'origine cérébrale.

Fifty-eight children or adolescents with cerebral palsy who presented an equino varus deformity of the foot were operated on between the age of 4 to 21 by tibialis posterior tenotomy (23 cases), tibialis posterior transposition (18 cases), tibialis posterior (10 cases) or anterior (6 cases) transfer on the cuboid, with triceps lengthening (37 cases). 56 adolescents were reviewed, 45 had achieved their growth. The foot was painless and weight bearing improved. 15 failures were caused by overcorrection in valgus (7 cases, in 5 of which the tendon was transferred on the cuboid) or under correction and recurrence of the deformity (8 cases). A. walking E.M.G. was not made but a clinical examination of voluntary and automatic activity pre and post operatively in 30 cases, which showed that even after tibialis posterior tenotomy a new muscular activity can appear. We recommend this procedure in the varus deformity of the fore foot associated with triceps lengthening in equino varus deformity when the foot is flexible. When the foot is stiff or in cases of under correction and after 10 years, triple arthrodesis is recommended.

[Lengthening of the triceps surae muscle in children with motor disorders of cerebral origin performed before the age of 6. Results at the end of growth]. / L'allongement du triceps sural chez l'enfant infirme moteur d'origine cérébrale réalisé avant l'âge de 6 ans. Résultats en fin de croissance.

Thirty-seven patients with cerebral palsy aged between two and six years had a lengthening of the triceps by various methods: gastrocnemius recession alone or combined with soleus lengthening (Green), lengthening of the tendon Achilles by the Green method, or by Z-lengthening. All were reviewed at the end of growth. Recurrence was more frequent, in two cases out of four, in those operated on before the age of three years. There were four recurrences out of 10 in those operated on between three and four years and four out of 23 among those between four and six years. There were three cases of talus, only one of which was severe in a child who had not yet walked. There was no other deterioration of function. In six cases operated on before they had begun to walk, two did not achieve walking because of the severity of their motor state. Recurrence was more frequent in hemiplegic than in diplegic children. Operative technique must be precise. Lengthening of the tendon Achilles is preferable to gastrocnemius recession. Plaster casts are kept on for three weeks. Whilst splintage is ultimately unnecessary, it is necessary to re-educate the triceps muscle.

[Flexion of the knee in poliomyelitis. Results and indications for femoral and tibial osteotomies]. / Le flexum du genou dans la poliomyélite. Résultats et indications des ostéotomies fémorales et tibiales.

Of 62 patients with a fixed flexion deformity of the knee due to poliomyelitis, 36 were treated by femoral osteotomy and 26 by tibial osteotomy. Their ages ranged between 10 and 30 years, with an average of 16. In 37 of the patients other procedures were also performed. The aim of operation was to enable walking in 6 patients, to allow walking without, or with smaller, calipers in 21, and to allow walking without additional help in 35. These objectives were usually achieved; failure was due to technical error or to lack of appreciation of residual muscle power. The operation is indicated for flexion deformities of less than 30 degrees, and as an adjunct to other procedures. The level of osteotomy is decided from lateral radiographs taken before operation.

[Extensive excision of the upper end of the femur in children with motor handicap of cerebral origin]. / Résection élargie de l'extrémité supérieure du fémur chez l'enfant infirme moteur d'origine cérébrale (I.M.O.C.).

The authors have resected the upper part of the femur on 17 occasions in 12 teenagers suffering from spastic paraplegia or quadriplegia. The patient had no hope whatsoever of walking. The hips were dislocated and painful. This type of procedure is justified by failure of other procedures aiming to stabilise the hips in spastic patients. It was performed by a double approach-anterior and posterolateral. The quality of post-operative care is very important. After an average follow-up of 3 years the results were satisfactory in 8 patients. Three had post-operative complications of pain, increased spasticity and secondary fracture of the femur. The indications must be considered because secondary bone formation may take place and decrease the quality of the result. The main goal is to diminish pain and increase comfort.

[Congenital metatarsus varus. Value of orthopedic treatment and role of surgery. Apropos of 290 cases]. / Le metatarsus varus congénital. Valeur du traitement orthopédique et place de la chirurgie. A propos de 290 cas.

The authors have reviewed 252 children with congenital metatarsus varus as distinct from club foot with an adequate follow up. They describe fully conservative treatment of the condition and conclude that true correction was obtained in about 80 p. 100 of cases by the age of 3 years and that another 16 p. 100 healed between the ages of 3 and 5 years. There are only about 4 p. 100 of cases which are complex and do not correct. The authors emphasize the fact that among 96 p. 100 of corrections the conservative treatment had no influence whatsoever. When the foot does not correct by the age of 5 years surgery is indicated. Heymann's procedure of correction at Lisfranc's joint seems to give the best results.

[Hips in myelomeningocele and functional autonomy]. / Hanches de la myéloméningocèle et autonomie fonctionnelle.

The authors have reviewed 93 children with myelomeningocele and with hip involvement. Some had been operated upon and others had not. The results of surgery were often disappointing when the patient was evaluated in adolescence. A number of stiff hips and recurrences of dislocation were seen after tendon transplants, open reduction or osteotomies. Considering these results and the major non-orthopaedic problems of such patients, it is concluded that bilateral dislocations should not be operated on and that early treatment should be applied in unilateral cases mainly by osteotomy.