[The precautionary principle and the deontology code]. / Principe de précaution et code de déontologie.

Some is the mode of exercise or the speciality of the doctor, the medical act always involved risks for the patient. It is essential for a doctor to know the beneficial effects of therapeutic and capacity to measure the advantages and the disadvantages of them. The Code of ethics formally says it in several of its articles and points out the need for finding a right balance, "to recognize the limits of its competence, not to make run to the patient an unjustified risk". But the progress which does not cease accelerating is increasingly carrying risks. The prevention tries to draw aside from the known risks and identified and diligence, prudence and competence remain the essential virtues of the practitioner. The precaution challenges the decision maker until mentioning still unknown risks, which, if they are carried out, could engage its responsibility. This worrying progression causes interrogations within the medical profession. It do not have for the moment not satisfactory answers. This principle seems, in first analysis, more adapted to actions of public health than to an individual medical act. To measure risks for a definite population is with the possible rigour thanks to epidemiology. To prevent the totality of the risks incurred by an individual given following a medical decision would be to deny the nature even of the man, who is by definition an individual, testimoning of his personality, of his autonomy, and of his own identity.

[Is there any deontology of accompanying people at the end of life?]. / Y a-t-il une déontologie de l'accompagnement des personnes en fin de vie?

The thought on ethics, enhances by accompanying patients or human-beings reaching end of life, belong to major themes which have for years been dealt with by philosophers and monks. The physicians, who by nature accompany and live with their patient this life period a sometimes close relationship, have conceived within deontology a wonderful expression of what ethics inspired them. Reading articles 37 and 38 of the Code of Ethics brings a clear, precise and qualified answer to the question raised by the title. We easily find out the main principles which would be the guideline to the doctor's behaviour coping with this situation: providing suitable and continue cares to maintain the quality of a life which comes to end, respecting dignity. Relieving suffers, morally assisting, comforting the family, knowing to limit the cares reasonably. The sensitive and human expression sums up pretty well the particularities essential to all (physicians, health professionals or volunteers) who have accepted this heavy task.

[Patient education by the surgeon. Judicial aspects, ethical aspects, deontologic aspects]. / Information du malade par le chirurgien. Aspects judiciaires, aspects éthiques, aspects déontologiques.

AIM OF THE STUDY: The surgeon must inform his patient about eventual risks before any investigation with diagnosis purpose and before any therapeutic intervention. According to the decree of the first Civil chamber of the "Court of Cassation", the surgeon must be able to prove that this information has been given as required by the article 1315 of the civil code. This decree has created in France an important change in the relationship between surgeon and patient. The French Academy of Surgery has organized a special session to study this problem in terms of legal, ethical and deontological aspects. CONCLUSIONS OF THE ACADEMY: The Academy confirms the necessity to give information to the patients and suggests that the modalities of the information be prepared by the medical societies, the "Conseil National de l'Ordre des Médecins", eventually by ethical committees and legal organizations concerned with medical questions, in view of a common use in all French juridictions. According to the Academy, it is necessary to determine the limits of the information to be given to the patient concerning the most common risks and those with the most serious consequences, in order not to disturb him psychologically. The Academy wishes that necessary and sufficient means be indicated in order for the surgeon to be able to prove that the information has really been given.

[Evolution of medical responsibility and code of ethics]. / Evolution de la responsabilité médicale et code de déontologie.

The evolution of the medical responsibility cannot escape from the determining influence of the scientific progress, but it is also significantly influenced by sociological and psychological factors that often are more difficult to analyse. If the ethical rules express the physicians' obligations in legal terms, it perfectly determines the spirit which must drive every physician thus revealing his sense of responsibility. This concept of the medical responsibility distinguishes and differentiates itself from the penalty responsibility and from the compensation responsibility which only takes place in the context of the compensation for a harm caused. The acquisition of the prime sense of the responsibility is a product of a background dominated by the experience, the example, the conscience. The expression of the medical responsibility is most of all personal, but more and more fits in with the public health issues and becomes a collective responsibility. Finally in order to meet the more and more accurate specialists' demands, the physician's responsibility which must remain within the boundaries of his competence must be fulfilled in the frame of a team. This dimension imposes on him new regulations that affect the quality of the relationship between the various contributors. An evolution of the responsibility thus grows according to the progress and within the adapted scope of ethics.

Limb lengthening in children using the Ilizarov method.

By limb lengthening with the Ilizarov method on 24 children with an average age of 11 years, the average lengthening was 50 mm. The results were judged by the healing index and the corticotomy index. The average time for lengthening was 50 days. The healing index was on average 35 days per centimeter. Five complications were noticed during the first stage of the surgical procedure. During the lengthenings, eight cases of joint stiffness were observed, and in five normal biomechanical axes of the limb were modified. Only one abnormal biomechanical axis was perfectly corrected of eight present before surgery. There were three wire-tract infections. Only 13 of 26 patients were without any complications. The Ilizarov method had a lower rate of complication than the Wagner technique, however. Open corticotomy, as modified by De Bastiani, may accomplish lengthenings with somewhat fewer complications.

[Palliative treatment of myopathies. Contribution of surgical treatments]. / Traitement palliatif des myopathies. Apport des traitements chirurgicaux.

The knowledge acquired over the last few years on Duchenne's muscular dystrophy (DMD) serves as the basis for management of all types of myopathy. After reviewing the current classification of muscle dystrophies and the principles of orthopedic management of these conditions, a historical perspective of surgical procedures used in DMD is presented. The various modes of discovery of myopathy are described. Deformities of the limbs and spine related to DMD are reviewed and their outcome is detailed. In DMD patients, the surgical procedures described allowed to delay loss of the ability to walk by 1 year 7 months to 3 years 8 months according to the severity of the condition, and provided significant improvements in quality of life. Surgical stabilization of the scoliosis ensured preservation of comfortable sitting in every case, as well as preservation of autonomous upper limb motion, with a low rate of complications. Surgical indications in DMD are well-established and serve as the basis for making surgical decisions in the other myopathies, except during early infancy. The principles and orientations of treatment of the other myopathies are defined, in the light of the variability of lesions and of the rate of muscle function loss. In these non-DMD myopathies, medical and surgical treatments are of as yet unquantifiable benefit but provide a substantial improvement in quality of life.

[Surgery of the lower limbs in Duchenne's muscular dystrophy]. / La chirurgie des membres inférieurs dans la dystrophie musculaire de Duchenne.

Seventy-one children had surgical procedures on hips and/or knees and/or feet contractures before or after the age of loosing gait. Gait has been continued on 1 year and 7 months to 3 years and 8 months according to the evolving type of Duchenne Muscular Dystrophy (DMD). After analysis of results of the surgery upon contractures, surgical procedures have been determined for each joint. Before loosing gait, but when contractures were all present, surgery prolonged on gait without orthosis and relieved of physiotherapy. During the 6 months after loosing gait, surgery allowed to recover same walking ability more often with orthesis. After loosing gait, surgery gave a better comfort of life to the child and his family.

[Patellar instability in children. Result of transposition of the medial third of patellar tendon]. / Instabilité rotulienne chez l'enfant. Résultat de la transposition du tiers interne du tendon rotulien.

Before bony maturity, the treatment of the recurrent dislocation of the patella is based on tendinous transfers. These distal procedures were often combined with proximal procedures on the medial or lateral patellar retinaculum and vastus medialis muscle. For the purpose of analysing efficacity of the medial third tendon transfer to the distal and deep part of the medial collateral ligament before the bony maturity, 24 children have been reviewed with a post operative follow up of 14 months to 6 and half years. There were 4 boys and 20 girls between 7 to 15 years old at the time of surgery. The troubles duration before the operation was from a few days to 4 years and the pathology was very often bilateral (40 knees). The recurrent dislocation of the patella was present 6 times, an instability 25 times and a traumatic dislocation 9 times. The technical procedure was every time a stabilisation with the transfer of medial third of the patellar tendon, associated except in 6 cases with a correction of the patellar motion by patellar retinaculum plasties. The functional result has been evaluated according to the sport activity and the ordinary life, with very hard criteria according to patient's age. Twenty-four times the result was excellent (60 per cent), 8 times good (20 per cent) and fair 8 times. Two complications have been observed. The improvement of the trochlea angle, and the trochlea deepness have been significant. Sixteen patients (27 knees) have been reviewed after the bony maturity and no growth disturbance of the tibial tuberosity has been observed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Osteoarthritis of the hip in children. Proposal for a classification of sequelae guiding therapeutic indications]. / L'ostéoarthrite de hanche chez l'enfant. Proposition d'une classification des séquelles guidant les indications thérapeutiques.

Twenty-six hips in 21 patients were available at mean follow up of 5 years in a retrospective functional and radiographic analysis for the purpose of examining the late effects of infantile septic arthritis. Poor results after reconstructive efforts following hips joint sepsis suggest help classification of bony deformation. Epidemiologic and clinical findings were analysed. Late diagnosis and prematurity were found as poor forecast facts.

The treatment of scoliosis in Duchenne muscular dystrophy.

There are not, as yet, clear indications for the surgical management of scoliosis in Duchenne muscular dystrophy (DMD), taking into account the varying severity of the clinical course. Monitoring the vital capacity can be most important for the indication and timing of surgery. In some cases, delaying surgical intervention with conservative management using spinal braces and wheelchair inserts can permit the restrictive lung syndrome to advance to the point that surgery will be contraindicated. Ten such patients conservatively treated for an average of 5 years exhibited perhaps a slower progression but ultimately an advanced deformity. From a second group of five carefully selected and surgically treated patients, indications for spinal surgery were reviewed. Surgical intervention should be prophylactically undertaken when there is high risk of a rapidly evolving curve with a severe restrictive lung syndrome.

[Preventive and therapeutic approach to deep phlebitis of the leg]. / Attitude thérapeutique préventive et curative en face des phlébites profondes des membres inférieurs

Preventive and therapeutic approaches in cases of deep thrombosis of the lower limbs.