Developmental dysplasia of the hip in neonates: evolution of acetabular dysplasia after hip stabilization by brief Pavlik harness treatment.

BACKGROUND: The recommended treatment duration in neonates with developmental dysplasia of the hip (DDH) varies depending on whether prolonged Pavlik harness therapy is believed to favourably affect the course of the acetabular dysplasia. According to one theory, several months of additional Pavlik harness therapy after achieving hip reduction contributes to correct the acetabular dysplasia. Another theory holds that hip dislocation induces the acetabular dysplasia, which corrects spontaneously once the femoral head is properly seated in the acetabulum. Here, we evaluated this second theory by studying outcomes after early brief Pavlik harness therapy. HYPOTHESIS: Acetabular dysplasia associated with neonatal hip instability undergoes self-correction provided stable hip reduction is achieved very early after birth. Therefore, the duration of Pavlik harness therapy can be substantially shortened. MATERIALS AND METHODS: We defined hip instability as either reducible hip dislocation or a very easily dislocatable hip with a soft clunk precluding determination of spontaneous hip position as dislocated or reduced. Static and dynamic ultrasound scans were obtained. Patients with ultrasonographic instability (pubo-femoral distance>5mm with less than 50% of coverage) underwent a second physical examination and received treatment. We re-evaluated 42 abnormal hips in 30 patients after a mean follow-up of 6.7 years (range, 5-14 years). Mean age at treatment initiation was 5 days (range, 1-15 days) and mean treatment duration was 34 days (range, 15-75 days). RESULTS: Mean acetabular angle was 20° (range, 12°-30°) and mean Wiberg's lateral centre-edge angle was 30° (range, 22°-35°). Blunting of the lateral angle of the bony roof was noted in 8 hips at last follow-up. In 1 patient whose hip was stable clinically but unstable by ultrasonography at 21 days of age, recurrent dislocation occurred at 5 months of age. The Severin class was 1a in all patients. DISCUSSION: Despite continuing controversy about whether hip dislocation induces dysplasia or vice versa, the need for early treatment is universally recognised. The optimal treatment duration, however, remains debated. Proponents of the familial determinism of DDH consider that acetabular shaping is genetically programmed when the femoral head is centred in the acetabular socket. Others advocate routine prolongation of Pavlik harness therapy for 2 months or longer, based on the opinion that this strategy decreases the dislocation recurrence rate and that mechanical hip unloading may promote correction of the dysplasia. Mean treatment duration in our population was 34 days and our sole objective was to treat the instability. The hip was reduced and held in its proper position long enough to allow sufficient capsule and ligament tightening to stabilise the hip. Under these conditions, the acetabular dysplasia underwent self-correction that was not related to treatment duration. CONCLUSION: Very early Pavlik harness therapy to ensure rapid hip reduction and stabilisation optimises the potential of the acetabulum for spontaneous remodelling. LEVEL OF EVIDENCE: Level IV, retrospective study.

Paralytic congenital talipes equinovarus of unknown origin: A new entity. Multicenter study of 42 cases.

BACKGROUND: Paralysis of the lateral and/or anterior leg muscles can lead to relapse of treated talipes equinovarus. HYPOTHESIS: The muscle function impairment is due to isolated permanent paralysis, and early palliative tendon transfer may prevent recurrence of the deformity. MATERIAL AND METHODS: Forty-two cases of congenital talipes equinovarus that recurred after conservative therapy were reviewed after a mean follow-up of 10 years. In 39 cases, second-line surgery was performed (posteromedial release, n=33; and muscle transfer, n=26). Outcomes were evaluated clinically. RESULTS: Separating the cases into two groups, based on whether muscle transfer was performed, showed a statistically significant difference: muscle transfer intended to restore eversion and/or dorsal flexion of the foot was associated with significantly better functional outcomes. DISCUSSION: In addition to providing etiological insights, the identification of paralysis in patients with talipes equinovarus can influence treatment decisions, depending on the nature of the muscle deficiencies, with the goal of preventing recurrences. Early muscle transfer to restore eversion and/or dorsal flexion of the foot may provide the best functional outcomes by minimizing the need for soft-tissue release. LEVEL OF EVIDENCE: IV, retrospective multicentre study.

Early correction of paediatric malunited distal metaphyseal radius fractures using percutaneous callus osteoclasis ("Calloclasis").

INTRODUCTION: Closed reduction of secondary displacements of distal metaphyseal radius fractures is an easy procedure only when performed within the first ten to fifteen days post-trauma, prior to the occurrence of malunion. When a hard bony callus prevents proper reduction, an open osteotomy is generally advocated. HYPOTHESIS: We suggest the use of a less invasive technique which aims at correcting early malunion when closed reduction is made impossible: the percutaneous callus osteoclasis. MATERIALS AND METHODS: Callus osteoclasis consists in a series of multiple bone-drilling in a postage stamp pattern performed under image intensifier using a large diameter pin, at a distance from the growth plate. Once the bone has been weakened, reduction is obtained by using the pin as an intrafocal lever. The pin is then pushed through the opposite cortex to ensure postero-lateral stabilization. RESULTS: Twenty-one patients were managed using this technique and reported good results with no complications. DISCUSSION: This technique offers a low aggressive management of malunions and may be performed within two to six weeks after trauma. LEVEL OF EVIDENCE: Level IV. Multicenter retrospective study.

Posteromedial elastic stable intra-medullary nailing (ESIN) in volarly displaced metaphyso-diaphyseal distal radius fractures in child.

INTRODUCTION: The distal metaphyso-diaphyseal fractures of the radius with volar angulation are generally considered unstable. Too distal to be treated with classic elastic stable intramedullary nailing (ESIN) via a laterodistal approach and too proximal to be stabilized with simple conservative treatment, they are sometimes treated by plating. PATIENTS AND METHODS: To avoid the disadvantages of the open exposure necessary for this latter fixation and to prevent volar angulation while respecting the curvature of the radius, radial elastic nailing with posteromedial distal entry was used in 16 patients. These patients were reviewed with an average follow-up of 4.5 months. RESULTS: Six patients presented a mean volar angulation of 7°, eight a mean posterior angulation of 5.5°, and two were aligned at 0°. On the AP view, seven patients presented a mean residual varus of 6.5°, four a mean residual valgus of 5°, and five were at 0°. The pronating curvature of the radius and the radioulnar index remained intact in all cases. One case of extensor digitorum tenosynovitis was observed and disappeared after wire removal. DISCUSSION: For the unstable fractures of the distal third of the radius, certain authors propose systematic classic ESIN, but the lateral point of entry inevitably entails a varus misalignment, which is no longer the case if the entry is medial.

Tibial developmental field defect in valproic acid embryopathy: Report on three cases.

Prenatal exposure to valproic acid (VA) is associated with an increased risk of congenital malformations, especially limb defects like radial ray defects. Tibial developmental field defect in VA embryopathy remains exceptional. We report on three patients presenting with tibial hypo/aplasia associated with either femoral bifurcation or radial ray defect following prenatal exposure to VA. Femoral bifurcation and tibial agenesis has been described in the Gollop-Wolfgang complex and in the tibial agenesis-ectrodactyly syndrome. Tibial agenesis has also been reported in VACTERL association. The relation between prenatal exposure to VA and tibial agenesis is discussed.

Can Blount's disease heal spontaneously?

INTRODUCTION: In stage 1 of all currently accepted classifications for infantile tibia vara, the diagnosis is difficult between physiological bowing and true Blount's disease. There is no evidence of prognosis criteria for surgical treatment at this stage. PATIENT AND METHODS: We retrospectively studied a series of 26 patients born in the Indian Ocean area, presenting at stage 1 of the disease, in order to determine whether any of them were likely to heal without treatment. RESULTS: It was found that children seen at stage 1 of infantile tibia vara have a one-in-three chance of healing spontaneously. DISCUSSION: An alternative classification in three stages could then provide more suitable therapeutic indications: stage 0: possible Blount's disease (patient older than 2.5 years); stage 1: certain Blount's disease, active physis (+) (progressive varus, age >3 years, typical image with no epiphysiodesis bridging); stage 2: certain Blount's disease, inactive physis (-) (superomedial tibial bony bridge). LEVEL OF EVIDENCE: Level IV. Retrospective study.

Legg-Calvé-Perthes disease treatment by augmentation acetabuloplasty.

INTRODUCTION: Classical surgical treatments for Legg-Calvé-Perthes (LCP) disease are pelvic or femoral osteotomies, which are not without complications and inconvenience for the patient.An effective, relatively undamaging surgical alternative would improve this disease treatment. HYPOTHESIS: Augmentation acetabuloplasty using shelf acetabuloplasty is a recognized treatment for LCP disease, but its results have never been assessed in view of Herring's lateral pillar classification, the current reference in determining the prognosis of this disease. Assessment of its efficacy based on this system is therefore needed. MATERIAL AND METHODS: Over 15 years, 21 patients underwent shelf acetabuloplasty. Included in the study were children with a progressively subluxating femoral head and classified minimum grade B in the lateral pillar classification. The last follow-up had to be at least 12 months after surgery and include a clinical examination as well as an AP pelvic X-ray. RESULTS: The mean follow-up was 4 years and 3 months. Only two complications occurred, one of which required surgical revision. Shelf acetabuloplasty was considered effective (contained and Stulberg 1 or 2) in 13 cases and ineffective (lysed or Stulberg 3, 4, or 5) in eight cases. DISCUSSION: The lateral pillar classification demonstrated its high value in LCP disease in correlation with symptom onset. This series shows that at the medium term, shelf acetabuloplasty is as effective as pelvic or femoral osteotomies for children of any age and any level of disease severity, with fewer complications and less inconvenience for the patient. LEVEL OF EVIDENCE: : Level IV. Therapeutic retrospective study.

Green's surgical procedure in Sprengel's deformity: cosmetic and functional results.

INTRODUCTION: Multiple surgical options are available in the treatment of severe Sprengel's deformities and vary according to the selected muscle disinsertion site. We report here the functional and cosmetic results of the Green's operative technique. MATERIAL AND METHODS: We retrospectively reviewed cases of congenital elevation of the scapula operated on, between 1999 and 2007, at Saint-Denis Regional Hospital Center. Clinical and radiographic examinations along with parents questioning were performed. RESULTS: This study included eight children with a mean follow-up of 4.5 years. Improvement occurred in all cases: the appearance was improved by one grade in three children and two grades in three other children, according to the Rigault's classification system. Cosmetically, all families were satisfied with the final result of the treatment. A case of complete brachial plexus palsy (BPP) that resolved spontaneously within 7 months was observed. DISCUSSION: Sprengel's deformity is an unusual skeletal abnormality. The Green's operative technique allows both lowering and rotation of the scapula. Muscle attachment is distally, rather than proximally, modified which provides a better biomechanical effect: muscles are reattached higher than the acromiothoracic junction's rotation center. The Green's scapuloplasty has been rarely reported in literature, whereas the Woodward procedure remains the reference standard. However, both techniques report similar results. Our choice was based on a better impression in terms of operative approach and improved muscle levers' distance adjustment to the fulcrum. Finally, resection of the superomedial portion of the scapula which is fixed to the rib cage into a pocket of the latissimus dorsi seems to provide a more efficient correction. LEVEL OF EVIDENCE: Level IV, retrospective therapeutic study.

[Early short-term treatment of neonatal hip instability with the Pavlik harness]. / Traitement précoce et court des instabilités néonatales de hanche par harnais de Pavlik.

PURPOSE OF THE STUDY: The purpose of this work was to study early short-term treatment of reducible dislocated or very unstable dislocated hips using the Pavlik harness. This approach is based on the theory of that dislocation favors dysplasia and that spontaneous correction occurs if the hip is reduced and stable. Very easily dislocated hips have been qualified as "major instability" if voluntary dislocation was easily achieved. In this case, it is very difficult to predict whether postnatal capsuloligamentary retraction will occur in the reduced or dislocated position. MATERIAL AND METHODS: We retained for study 34 patients with 44 pathological hips; 15 hips presented reducible dislocation and 29 major instability. Treatment began early at 3.4 days of life on average and lasted 27.9 days. RESULTS: Outcome was very good for 39 hips with stabilization and spontaneous correction of the acetabular dysplasia, good in four with late correction of the dysplasia, and a failure in one. There were no major complications, none of the patients presented post-reduction osteochondritis. DISCUSSION: Two different entities can be distinguished: dislocation producing dysplasia which is symptomatic neonatally and would imply pathogenic in utero events, and primary dysplasia which can be asymptomatic at birth and for which correction is not spontaneous. If the hip is symptomatic at birth, treatment should begin immediately and be continued to confirmation that the reduced hip is stable, i.e. about three to five weeks on average. Simple dysplasia of dislocatable hips should be excluded from this strategy because of their favorable spontaneous course. Likewise for irreducible dislocated hips because of the higher risk of complications. Under these conditions, this therapeutic strategy is effective for the reduction, stability, and correction of dysplasia achieved in 97.7% of cases without increasing the rate of complications.

[Bed rest and skin traction for Perthes' disease: review of the literature]. / La traction au lit dans le traitement de la maladie de Legg-Perthes-Calvé: revue de la littérature.

Long-term bed rest with skin traction, which isolates children with Perthes' disease from their social and educative environment, could be considered as incompatible with the ethics of modern therapeutics. Adaptation for home care has been proposed, but remains burdensome. We searched the literature in order to ascertain the real advantages and disadvantages of bed rest with skin traction and to evaluate the statistical value of published results. Considering that poor outcome is the natural course of the disease in 10-20% of patients, and that the number of patients in this group is further divided according to age and treatment, the number of patients in each treatment arm is rarely sufficient to validate any given treatment. For hips with limited abduction, traction does not appear to be warranted. Conversely, traction could be useful if the aim is to modify the natural course of the disease in precise situations, for example for Herring group B and or B/C patients with bone age above 6 years with a stiff hip. In this case, skin traction should not last more than two weeks and, to be considered useful, should achieve 30 degrees abduction documented on the ap view.

[Immediate weight bearing after treatment of stable epiphysiolysis]. / La mise en charge postopératoire précoce après traitement par vissage des épiphysiolyses stables.

PURPOSE OF THE STUDY: The purpose of this study was to ascertain whether immediate weight bearing after surgery for chronic or stable epiphysiolysis treated with a single percutaneous screw increases the risk of greater displacement. MATERIAL AND METHODS: Epiphysiolysis procedures (n=30) performed in 25 patients were reviewed retrospectively. One percutaneous screw was inserted under fluoroscopic control in all cases. For ten patients (from 2002), weight bearing was allowed immediately after surgery. The Southwick grading system was applied to classify each epiphysiolysis into one of three stages according to the cervicoepiphyseal angle measured on the lateral radiograph. Clinical and radiographic controls were obtained in all children at 1, 3, 6, and 12 months. Outcome was assessed using the Heyman and Herndon criteria. RESULTS: The study population included 17 boys and 8 girls (mean age 12 years 18 months). The left side was involved in 12, the right in 8 and both in 5. Weight bearing was allowed immediately after surgery in 10 patients with a stable epiphysiolysis (4 stage I, 5 stage II, 2 stage III). Time to weight bearing was 3 months on average for the others. Mean follow-up was 4 years (range 1-8 years). Clinically, none of the ten patients presented pain or limping at last follow-up. Abduction was limiting in 9 and internal rotation in 19. There was no increase in the displacement for patients with immediate weight bearing. DISCUSSION: Most teams advise against weight bearing for 6 weeks to 3 months. We were unable to find any pathophysiological reason for this attitude. It would be more logical to wait until complete fusion of the subcapital growth cartilage before authorizing weight bearing. This raises the question of the effect of this practice on postoperative displacement For stable epiphysiolysis, there is no evidence that not allowing weight bearing had an effect on the evolution if the screw is correctly positioned and at least 4 or 5 spires are engaged within the epiphysis.

[Physeal distraction for limb length discrepancy and angular deformity]. / La distraction physaire dans les inégalités de longueur et déviations angulaires des membres.

PURPOSE OF THE STUDY: Physeal distraction or chondrodiastasis uses the growth plate as a zone of least resistance. Application of force thus provokes distraction and opening of the plate (Salter and Harris type I epiphyseal detachment). Progressive lengthening allows room for regenerate bone and enables limb lengthening and correction of angular deformations. MATERIAL AND METHODS: Twenty chondrodiastasis procedures were performed in fifteen patients. Mean age was 14.4 years (10.3-15.7). The underlying causes were trauma (n = 6), constitutional deformation (n = 8), infection (n = 2, distal lateral femoral epiphysiodesis), and malformation (n = 4). The localizations were: proximal tibia (n = 11), distal tibia (n = 4), distal femur (n = 4), distal radius (n = 1). The surgical procedure involved installation of an external fixator on either side of the physis after planification of the desired correction and taking into account the remaining growth potential of the physis. The distraction was performed by the patient at the rate of 1 mm per day. A one-sided external fixator was used for eleven patients (distal femoral correction and proximal tibial hemichondrodiastasis for angular deformation) and a circular fixator (to control 3D correction) in nine. Complications were noted according to the four grades of severity described by Caton. RESULTS: Mean follow-up was 26.1 months. Epiphyseal detachment was achieved in all patients, even in the presence of an epiphysiodesis bridge, in 7.7 days on average (2-15 days). Mean lengthening was 4.75 cm, mean angular correction was 22.2 degrees (mean preoperative angle 20.5 degrees ). For chondrodiastasis (symmetrical physeal distraction), the mean duration of correction was 4.6 months (1-9), mean time to healing was 8.3 months (4-13) and mean healing index was 55.6 days/cm (Verone). For hemichondrodiastasis (asymmetrical physeal distraction), mean duration of correction was 1.3 months (1-3), and mean time to healing was 2.7 months (2-5). The healing index was different and was 3 days per degree. Complications were studied using the Caton classification. There were 17 (85%) benign complications (not requiring revision under anesthesia) and 6 (30%) serious complications (requiring anesthesia and unplanned revision). There were 2 (10%) severe complications (knee flexion, ankle equinus). DISCUSSION: Chondrodiastasis has specific complications, mainly involving the distal femur (stiff knee, risk of septic arthritis). It provides rapid in situ correction resulting from epiphysiodesis bridges. The resection step proposed by Bollini is not necessary, but the growth plate is definitively sterilized. This implies that the procedure be used for preventive lengthening, depending on the predicted limb length discrepancy. This notion limits indications to older children. Besides the fact that several deformations can be corrected simultaneously, this technique does not require osteotomy and respects vascular supply to the regenerative tissue. It involves the physis responsible for the angular deformation or limb length discrepancy. It does not require internal fixation nor bone grafting and can be performed with weight bearing. Finally, the procedure can be adjusted as needed during the correction phase, with the patient in the standing position.

[Elastic sliding central medullary nailing with osteogenesis imperfecta. Fourteen cases at eight years follow-up]. / L'embrochage centro-médullaire coulissant dans l'ostéogenèse imparfaite. Quatorze cas avec un recul moyen de 8 ans

PURPOSE OF THE STUDY: Elastic sliding centromedullary nailing (ESCN) proposed by Métaizeau in 1987 for the prevention and treatment of limb fractures in osteogenesis imperfecta has never been evaluated. A multicentric serie was studied in order to evaluate results of these procedure. MATERIAL AND METHODS: Thirty-six ESCN procedures were performed in fourteen patients. Percutaneous pinning was used for the femur and distal tibia and arthrotomy for the distal femur as needed and in all cases for the proximal tibia. The pins were bent in compliance with the principles of the ESCN system. The ends of the pins were bent back to form a U pushed into the epiphysis. Reaxing osteotomies required minimal incisions. Age at the first procedure, the number of procedures and complications, and time between procedures were recorded. Pin overlap and the angle formed were also recorded. Pin gliding was evaluated. Ability to walk with or without assistance was noted. RESULTS: The medullary canal measured 4 to 10 mm. The first procedure was performed at a mean age of four years (range 15 days to 10 years). Follow-up was eight years (range 1-12). There were 2.5 procedures per patient (range 1-5). Pins had to be changed in 75% of the bone segments. Mean time between two procedures was 3.2 years. There were no cases of defective sliding or infection. There were four cases of secondary fracture with a mean 30% pin overlap, two pin migrations, one nonunion, and one shortening. The majority of the complications occurred after the age of five years. At last follow-up, three patients could not walk, four walked with aids, and eight without aids. DISCUSSION: The advantages of the technique (size of the pins, nailing without reaming, pin sliding in all cases, low cost) must not overshadow the drawbacks (risk of pin deformation and migration, secondary fracture). Secondary fractures might be limited by discrete valgus of the femoral shaft and preventive pin change when the angle formed approaches 30 degrees and when there is only 30% overlap left. Use of telescopic nails before the age of five years increases the risk of complications while most of the complications observed with ESCN occur after the age of five years. Twenty-five percent of the ESCN complications involved only the femur. The percent of secondary fractures was less than with telescopic nailing (3.6% versus 11%) but there were more cases of nail migration. All pins slid, compared with 6% failure of elongation with telescopic nails. Although proof is not available, surgical treatment of osteogenesis imperfecta before the age of five years appears to provide more rapid functional progress. CONCLUSION: Sliding centromedulary nailing is an attractive alternative before the age of five years. In older children and to the end of growth, telescopic nail or pinning should be discussed although pinning may permit more secondary fractures which can be limited by rigorous surveillance of pin position.

[Shelf acetabuloplasty in Legg-Perthes-Calve disease]. / La butée ostéoplastique dans l'ostéochondrite primitive de la hanche.

PURPOSE OF THE STUDY: The purpose of this study was to demonstrate the contribution of shelf acetobuloplasty for the treatment of Legg-Perthes-Calve disease. MATERIAL: Eighteen children with Legg-Perthes-Calve disease were operated on between 1992 and 2001. Mean age at diagnosis was 7 years 2 months, and mean age at surgery was 8 years 5 months (range 5-13 years). Mean motion was limited -25 degrees in abduction and internal rotation preoperatively. The radiological classification was: 2 Catterall II Herring B with signs of risk for the head, 8 IIB, 1 III C, 2 IV B, 3 IV C, and 2 at the sequelar stage. Mean excentration was 6.5 mm and mean overhang was 10.2 mm. METHOD: The indication for surgery was aggravation of the excentration or advanced revascularization. An iliac graft was embedded in the supralimbic and covered with a rectus femoris tendon which, left continuous, provided elastic support. A bermuda cast was used in 17 cases and immediate weight-bearing in 11. The patients were hospitalized 36 hours. RESULTS: Sixteen patients were reviewed at mean follow-up of 3 years 2 months (2 lost to follow-up). There were no complications. Clinically, the patients were pain free. Three patients had persistent limping 10 moderate limitation of motion, and three had severe stiffness. Radiologically, head covering was good in 15 cases, and joint congruency was achieved in 15 (11 of which were concentric). Shelf acetabuloplasty was considered useful in 12 cases, not useful in 1 after complete lysis of a poorly positioned graft, and of uncertain usefulness in 3 (including 2 cases treated at the sequalar stage). DISCUSSION: Femoral osteotomy for varisation and pelvic osteotomy for reorientation or enlargement of the acetabulum are effective but have certain drawbacks (limitation of abduction, leg length discrepancy, reintervention to remove material). The excellent integration of the shelf graft at mid-term is a good sign of correct head-acetabulum adaptation, with radiological and clinical results similar to other techniques. Joint stiffness and limping are observed in very severe forms where the prognosis depends on the stage of the disease. CONCLUSION: The patients in this series have not yet all reached maturity. Shelf plasty is a rapid, easily-performed, and safe means of enabling weight-bearing in Legg-Perthes-Calve hips undergoing excentration and beginning revascularization.

[Rotational osteotomy technique for congenital radio-ulnar synostosis with central medullary nailing and external fixation]. / Ostéotomie de dérotation des synostoses radio-ulnaires congénitales avec embrochage centro-médullaire et fixation externe.

PURPOSE OF THE STUDY: Congenital radio-ulnar synostosis is a very uncommon condition. The functional impairment resulting from the complete pronation posture justifies rotational osteotomy. We present a series of six rotational osteotomies using the Hernigou-Goutallier technique. MATERIAL AND METHODS: The Hernigou-Goutallier osteosynthesis procedure is based on a centromedullary nail and two external fixation pins positioned in the ulna at an angle corresponding to the desired rotation. The nail is partially withdrawn to allow subperiosteal osteotomy in the synostosis via a horizontal incision between the two pins. After rotation, the osteotomy is stabilized with clamps holding the external fixation pins in parallel. RESULTS: Bone healing was achieved at two months in all six cases with no loss of correction. DISCUSSION: Among the different treatments proposed for radio-ulnar synostosis, the risk of vessel or nerve injury is high with screw-plate fixation despite shortening osteotomy. Palm-tree osteotomy raises the same risks and is more invasive and difficult to achieve. The rotational osteotomy technique presented here has the advantage of allowing local care more easily than with cast fixation. Another important advantage is that an overcorrection leading to vessel or nerve injury can be reversed without losing the axis, allowing progressive correction if necessary.

[Percutaneous lengthening of the Achilles tendon in children with cerebral palsy. Technique and results]. / L'allongement percutané du tendon d'Achille chez l'enfant infirme moteur cérébral. Téchnique et resultats.

We report a series of percutaneous lengthenings of the Achilles tendon in cerebral palsy children with equinus deformity in 25 patients due to retraction of the triceps surae. This technique has several advantages over open procedures. Based on our results and data reported in the literature, we emphasize the minimally invasive nature of this technique, the low rate of complications and recurrence, and the absence of secondary deformation of the calcaneus since over-lengthening is not compatible with the technique.

[Long-term outcome after Ilizarov corrective fixation for severe foot deformity]. / Devenir de la correction par appareil d'Ilizarov des déformations sévères du pied.

PURPOSE OF THE STUDY: Much work has focused on the short-term outcome after external fixation with the Ilizarov apparatus for treatment of severe recurrent or neglected foot deformity. No series has provided sufficient follow-up to allow an analysis of long-term stabilization. MATERIAL AND METHODS: We reviewed a series of 17 patients (21 feet) treated with the Ilizarov apparatus between 1988 and 1998 and reexamined after a mean 6-year follow-up. We assessed the risk of degradation of the initial result and quantified the need for secondary arthrodesis surgery. This series included 18 congenital clubfeet and 3 cases of acquired talipes equinus. Mean patient age was 15 years. RESULTS: Pain, morphology, weight bearing attitude and quality of shoe fit were assessed. Results at treatment end were very good in 16 cases, good in 4 and poor in 1. Two early recurrences required arthrodesis. At last follow-up, results were very good in 17 cases, good in 3, and poor in 1 (late recurrence with arthrogryposis). DISCUSSION: With 3 recurrences among 21 cases, results were maintained well over time in this series. Most of the recurrences were observed during the first year and never completely reproduced the initial deformation. In 2 out of 3 cases, the recurrence occurred on a secondary talipes equinovarus. Age was not a risk factor (only 2 feet have not reached maturity to date). The lack of over-correction at treatment end is a factor predictive of poor outcome. CONCLUSION: Long-term outcome demonstrated the stability of the results and the absence of severe complications and foot shortening, emphasizing the important contribution of Ilizarov fixation for severe foot deformity.

[Postero-medial elastic stable intramedullary nailing for anteriorly displaced distal diaphyso-metaphyseal fractures of the radius in children]. / L'embrochage postéro médial dans les fractures à déplacement antérieur de la jonction diaphyso-metaphysaire distale du radius chez l'enfant.

PURPOSE: To suggest a mechanically satisfying method to stabilize the unfrequent distal diaphyso-metaphyseal fractures of the radius, when they are anteriorly displaced, avoiding the classical use of an anterior osteosynthesis by plate and screws. MATERIAL AND METHODS: Ten cases of postero medial Elastic Stable Intramedullary Nailing are presented. Technically, a small postero medial approach with gentle retraction of extensors tendons is used. Then a hole is drilled through the postero medial metaphysis of the distal radius. A present wire is introduced intramedullary, directing its elastic forces in a postero lateral way, fighting against the displacement. DISCUSSION: The instability of this fracture often requires an osteosynthesis. Plating needs a larger incision and a direct control of the fracture (danger of injure of the growth plate, scar). Retrograd nailing through the proximal end of the bone can injure nerves. Then, postero medial Elastic Stable Intramedullary Nailing can be useful for stabilization of the diaphysometaphyseal fractures of the radius.

Blount's disease: classification and treatment.

Forty-three tibia vara in 27 patients were analyzed retrospectively in two centers. The criteria for diagnosis of the child form are discussed. A simple classification is suggested to facilitate the choice of treatment. In stage 0 (possible Blount's disease), the patient is younger than 2 1/2 years, and an observation period is indicated for gathering data. In stage 1 (confirmed Blount's disease and absence of medial metaphyseal bony bridge), known as physis+, a valgization osteotomy is proposed. In stage 2 (evidence of a medial metaphysoepiphyseal bony bridge) known as physis-, valgization osteotomy with lateral epiphysiodesis and treatment of the lower limb discrepancy is proposed. For stages 1 and 2, there are two possibilities: normal medial tibial plateau or sloping of the medial tibial plateau, indicating a transphyseal elevation osteotomy. When one-step correction is proposed for stage 2 disorder, external fixators such as Orthofix or Ilizarov devices are useful.

[Role of Cahuzac's operation in clubfoot varus equina revision surgery]. / Place de l'opération de Cahuzac dans la chirurgie itérative du pied bot varus équin.

PURPOSE OF THE STUDY: The authors report 24 cases of revision in recurrent club foot deformity. They assessed Cahuzac's procedure for treatment of the residual forefoot adduction. This procedure (opening of the first cuneo-metatarsal joint and proximal abduction osteotomy of the second, third, and fourth metatarsals) was generally associated with postero-medial, plantar release, and split tibialis anterior tendon transfer. MATERIAL: Twenty four procedures for 20 children at mean age of five years have been performed. The revision chart comprised 12 clinical and radiological items as proposed by Seringe. RESULTS: Seven feet were considered as excellent, 14 as good, 2 as fair, and 1 as poor. The mean follow-up was four years. DISCUSSION: Treatment of the adduction component with Cahuzac procedure is focused on the fore part of the foot, and on the calcaneo-pedal block by postero medial release, but never on the midfoot, as no Evans or Lichtblau's procedure has been performed. This series was compared to others procedures, and morphological results were equivalent. Cahuzac's operation is riskless for foot growth, and needs two approaches which can be useful for simultaneous procedures as split lateral transfer of tibialis anterior tendon. CONCLUSION: Metatarsal osteotomies (Cahuzac's procedure), associated with soft tissues release and split anterior tibial transfer, seems to be effective in surgical treatment of relapsed clubfeet, but the debate concerning the location of the adduction component of the deformity remains still open.