Arthroscopic treatment of calcaneonavicular coalition in children.

Calcaneonavicular coalition is a common source of pain and more or less severe flat and stiff foot in children. Classically, treatment consists in resecting the coalition using a dorsolateral approach. Good quality resection and interposition can prevent recurrence. The most common complications are infection, hematoma and neuroma. Arthroscopy offers a minimally invasive alternative, but the optimal approach remains undetermined. We describe a surgical technique with an approach based on the anterolateral process of the calcaneus, in three cases with 12 months' follow-up. Arthroscopic resection has certain advantages: recovery is quicker, and the esthetic result is better. For the instrumental portal, skin incision should be superficial, followed by blunt dissection of subcutaneous tissue to avoid superficial peroneal nerve injury. Although longer term follow-up is needed, arthroscopy seems to be an attractive minimally invasive technique in this kind of pathology.

Type IV-D thumb duplication: A new reconstruction method.

INTRODUCTION: In the Wassel type IV classification category, the thumb is duplicated from the metacarpophalangeal joint; this abnormality accounts for approximately 50% of the cases of thumb duplication. Type IV is divided into four subtypes in which the IV-D type, or convergent (9% of cases), is the most complex form because both thumbs are hypoplastic with a divergent metacarpophalangeal joint and a convergent interphalangeal joint. Reconstruction is prone to axis deformity and ligament laxity, whereas the Bilhaut-Cloquet technique's main pitfall is nail dystrophy. We propose a modified Bilhaut-Cloquet procedure to avoid these complications. MATERIAL AND METHOD: Four males (mean age: 11 months; range: 10-12 months) with IV-D thumb duplication were operated on using a modified Bilhaut-Cloquet procedure. SURGICAL TECHNIQUE: The skin is preliminarily marked, taking into account the excision of the central skin and the more hypoplastic nail of the two (most often the radial nail). Both proximal phalanges are split longitudinally and the central halves discarded. An oblique osteotomy is performed at the base of the distal phalanx of the ulnar thumb duplicate (the less hypoplastic) and the radial wedge is excised. The same osteotomy is applied to the distal phalanx of the radial thumb duplicate, but the radial wedge is preserved. The proximal phalanx and the bases of the distal phalanx are joined by bone suture. Axis correction and ligament stability are thus achieved without nail surgery. RESULTS: The patients were examined with a mean 24 months of follow-up (range: 12-36 months). The result was good in all four cases according to the Horii score. DISCUSSION AND CONCLUSION: This procedure combines an excision of the central part of the proximal phalanx and partial excision of the base of the distal phalanx. It provides axis correction and stabilization of the interphalangeal joint while avoiding subsequent nail dystrophy because a single nail is preserved. Preliminary results are encouraging: no axis deformity, instability or nail dystrophy has been noted. Nonetheless, the long-term results need to be evaluated. LEVEL OF EVIDENCE: IV retrospective study.

[Arthroscopic anterior capsular release in medial contracture of the shoulder secondary to brachial plexus birth palsy. Preliminary results]. / Arthrolyse antérieure de l'épaule sous arthroscopie dans les séquelles de paralysie obstétricale du plexus brachial. Résultats préliminaires.

PURPOSE OF THE STUDY: Retraction of the shoulder in internal rotation is observed in 25% of children with brachial plexus birth palsy (C5, C6 +/- C7). Early bone and joint deformities affecting the glenohumeral joint are the consequences. The stiff internal rotation requires surgical release which can involve the capsule and ligaments, muscles, or both. Internal release can be combined with muscle transfer to improve active external rotation. We report the results obtained with arthroscopic anterior capsular release combined with latissimus dorsi transfer. MATERIAL AND METHODS: From 1999 through 2006, fourteen children with a stiff shoulder in internal rotation secondary to brachial plexus birth palsy were managed in our unit. All had recovered biceps function six months after surgery. The glenohumeral dysplasia was analyzed on the preoperative magnetic resonance imaging. Pre- and postoperative passive external rotation (RE) were measured with the arm along the body and at 90 degrees elbow flexion. Internal rotation was measured using the Mallet score (hand-back test). Combined active abduction antepulsion was measured when the child was playing. Mean age at surgery was three years six months. Arthroscopic internal release was performed for eight children. All had an associated latissimus dorsi transfer. RESULTS: Among the 14 children managed in the unit, arthrolysis was not be performed in six, either because of the lack of an adequate electrode (two patients) or because the child presented posterior glenohumeral dislocation making it impossible to introduce the optic channel (four patients). Arthroscopic anterior release was performed for the eight other patients. These eight patients were reviewed at a mean three-year follow-up. Passive external rotation was improved, with a mean gain of 60 degrees with no recovery of passive internal rotation. The abduction antepulsion movement was also improved, mean gain 90 degrees . DISCUSSION: A stiff shoulder in internal rotation can develop during the first two years of life. Several techniques have been proposed for internal release. The origin of the progressive limitation of passive external rotation remains a subject of debate. Is it due to retraction of the internal rotators, or to capsule-ligament retraction, or both? In 1992, Harryman et al. demonstrated the role of the capsule and the coracohumeral ligament in limiting external rotation. Consequently, we have opted for early release (less than two years of age) using an arthroscopic method limited to the capsule and ligaments. Our results for passive external rotation are comparable to those reported by others. However, this technique enables preserved mobility for internal rotation. CONCLUSION: Arthroscopic anterior release limited to the capsule and the ligaments is an effective, minimally invasive technique. Leaving the internal rotator muscles intact preserves internal rotation of the shoulder and reduces the risk of anterior instability.

[Reconstruction of long bone defects with a vascularized fibular graft after tumor resection in children and adolescents: thirteen cases with 50-month follow-up]. / Reconstruction osseuse des os longs après exérèse carcinologique par l'utilisation de greffons fibulaires vascularisés chez l'enfant et l'adolescent.

PURPOSE OF THE STUDY: The vascularized fibular graft is a widely used technique for the reconstruction of long bone defects after tumor resection. Complications are not uncommon despite the presence of a good vascular supply. We report our experience with long bone reconstructions in children and adolescents after resection of primary malignant bone tumors. MATERIAL AND METHODS: This retrospective analysis included thirteen patients aged 4-17 years (mean age 12 years). Preoperatively, the pathological diagnosis was Ewing tumor (n=7), osteogenic sarcoma (n=5), neuroepithelioma (n=1). All patients except one were given chemotherapy preoperatively and postoperatively and four received adjuvant radiotherapy. Tumor resection created a gap (n=8) or involved resection-arthrodesis (n=5, three knees, one ankle, one elbow). All reconstructions used a vascularized fibular flap with a complementary corticocancellous autograft for seven. RESULTS: Complete carcinological resection was achieved in all cases. Mean follow-up was 50 months (range 12-144 months). There were no cases of local recurrence. Three patients presented lung metastasis; two patients died. Eleven of the twelve patients who underwent tumor resection involving the lower limb were able to walk with full weight bearing at 13.9 months (range 841 months), half of them without any supportive device. The MSTS score was 21/30 (range 7-29). Both ends healed for eleven of thirteen grafts. Outcome was good in four cases at 7.7 months (range 6-11), fair in seven (with 1-5 complementary procedures) at 14.8 months (range 10-45) and poor in two (nonunion at last follow-up). Among the fibular grafts which healed, primary healing of the distal end was noted in all cases, but not for the proximal end. Significant transplant hypertrophy was noted in 62% of patients, measured at mean 77.1% (range 25-128%). Complications were: skin necrosis (n=2), nonunion (n=4, three aseptic and one septic), disassembly (n=3 with two transplant fractures), and spontaneous fracture which healed (n=5, all but one treated orthopedically). There were four donor site complications: retraction of the hallux flexor (n=3), regressive paresia of the common fibular nerve (n=1). DISCUSSION: The rate of healing in this series was similar to earlier reports. Healing was always achieved for the distal focus but not for the proximal focus which receives its blood supply from a branch of the anterior tibial artery which is not harvested. The defective blood supply can thus hinder bone healing. It is necessary to spare the proximal quarter of the fibula or harvest a bipediculated graft. The rate of graft hypertrophy was also similar, as was the rate of complications. The MSTS score was lower due to the poor results obtained with resection-arthrodesis of the knee joint. Graft fractures and aseptic nonunion are the most common complications but septic complications are more serious and can threaten graft survival. Complications at the donor site are exceptional. CONCLUSION: Long bone reconstruction using an autologous vascularized fibular graft is a reliable technique providing satisfactory functional results. Complications can be prevented by making solid fixation and using a corticocancellous graft creating a favorable osteoinducing environment. A massive allograft is another solution providing good immediate mechanical stability.

[Scarf osteotomy of hallux valgus in children and adolescents]. / Traitement de l'hallux valgus de l'enfant et de l'adolescent par ostéotomie scarf.

PURPOSE OF THE STUDY: The aim of this study was to analyze the results of surgical treatment of hallux valgus using scarf osteotomy in children and adolescents. MATERIAL AND METHOD: Twelve children and adolescents (19 feet) operated on with scarf osteotomy were reviewed retrospectively with a mean follow-up of 15 months. Clinical and radiographic results were assessed. RESULTS: We obtained 10 good results (asymptomatic cases), 9 poor with residual symptoms such as pain or cosmetic problems. Two populations could be identified considering the metatarsus varus and distal metatarsal angle. Those with metatarsus varus >/= 10 degrees or normal distal metatarsal angle had good results. Those without metatarsus varus had poor results. There was no disturbance of growth. DISCUSSION: Scarf osteotomy can be used in children without risk of hindering growth. Nevertheless, good results can be achieved only in cases of true metatarsus varus and normal distal metatarsal angle. In other cases, a different osteotomy of the first metatarsal would be preferable.

[Recurrent aggressive chondroblastoma: two cases and a review of the literature]. / Récidive de chondroblastome agressif.

Chondroblastoma is a rare benign bone tumor. Treatment currently consists of curettage and bone graft. Prognosis depends basically on a relatively high rate of recurrence, between 5 and 38%, sometimes with local seeding of soft tissues and joint space. Such recurrences require wide resection with arthrodesis or even amputation. A 13-year-old girl with a humeral head chondroblastoma as treated by curettage and iliac bone graft. Six months later, a recurrence occurred with extension into the rotator cuff and the metaphysis. Remission was achieved by extensive surgical resection and hemiarthroplasty. The second case was a 14-year-old boy with a chondroblastoma of the right talus. He was treated by curettage and packing with bone substitute. After 2 recurrences with soft tissue and intra-articular extension, we performed a wide resection with reconstruction using a vascularized fibular graft. Many other cases in the literature illustrate such complications. We tried to find factors predictive of recurrence. Recurrence is observed when curettage was incomplete or when tumor cells were disseminated during surgery. Chondroblastoma is a benign bone tumor, but prognosis depends on the rapidity and severity of recurrence. Curettage should be as complete as possible and care should be taken to avoid contaminating the operative field.

Kienböck's disease and multiple hereditary osteochondromata: a case report.

A case of bilateral forearm localization of multiple hereditary osteochondromata and unilateral Kienböck's disease is reported. Ulnar minus variance is frequent in both diseases. Carpal slip is often found in multiple hereditary osteochondromata. In this case, the extremity having both multiple hereditary osteochondromata and Kienböck's disease had no carpal slip. This might have produced an excess load on the lunate, which might have provoked Kienböck's disease.

Natural course of osteochondritis dissecans in children.

Results are reported from an absence of physiotherapic, orthopaedic, or surgical treatment in 31 cases of osteochondritis dissecans in 24 children. The mean age at diagnosis was 11 years and 4 months, and all the children were suffering from pain for an average of 3 months. None of these children were treated, except for instructions to discontinue involvement in sports activities until their pain had disappeared. In all cases pain disappeared, and these children have all returned to their former activities. According to x-ray findings, 30 lesions disappeared totally, although there was one case of a loose body. As a result, absence of treatment is recommended for osteochondritis dissecans in children.

Imaging evaluation of subluxation in Legg-Calvé-Perthes disease: magnetic resonance imaging compared with the plain radiograph.

The aim of the study was to evaluate the advantages of magnetic resonance imaging (MRI) in determining subluxation in Legg-Calvé-Perthes (LCPD) disease. Twenty-six patients with unilateral LCPD received 33 MRI and plain radiographs. For each patient, acetabulum head index (AHI) was measured on both hips (affected and unaffected) in a blinded fashion. Measurements were made from the cortical bone margin on the plain radiograph and from the cartilaginous surfaces on MRI. On the unaffected side AHI was 92.8% on the plain radiograph and 85% on MRI. On the affected side, AHI was 87% on the plain radiograph and 77% on MRI. These differences were statistically significant. With regard to the unaffected side, the femoral head should be considered subluxated if AHI is less than 86% on the plain radiograph and less than 77% on MRI. On the affected side, in 14 cases the femoral head was well-contained on both the plain radiograph and MRI. In 11 patients the femoral head was subluxated both on the plain radiograph and on MRI. In 8 patients the femoral head was well-contained on the plain radiograph but subluxated on MRI. This was due to thickening of the cartilaginous portion of the femoral head, which was clearly seen on MRI. MRI appeared to be more sensitive in determining the subluxation of the femoral head during the active phase of LCPD.