Intramuscular psoas lengthening during single-event multi-level surgery fails to improve hip dynamics in children with spastic diplegia. Clinical and kinematic outcomes in the short- and medium-terms.

BACKGROUND: In children with spastic diplegia, hip extension in terminal stance is limited by retraction of the psoas muscle, which decreases stride propulsion and step length on the contralateral side. Whether intramuscular psoas lengthening (IMPL) is effective remains controversial. The objective of this study was to assess the impact of IMPL as a component of single-event multi-level surgery (SEMLS) on spatial and temporal gait parameters, clinical hip flexion deformity, and hip flexion kinematics. HYPOTHESIS: IMPL as part of SEMLS does not significantly improve hip flexion kinematics. MATERIALS AND METHODS: A retrospective review was conducted of the medical charts of consecutive ambulatory children with cerebral palsy who had clinical hip flexion deformity (>10°) with more than 10° of excess hip flexion in terminal stance and who underwent SEMLS. The groups with and without IMPL were compared. Preoperative values of the clinical hip flexion contracture, hip flexion kinematics in terminal stance, and spatial and temporal gait parameters were compared to the values recorded after a mean postoperative follow-up of 2.4±2.0 years (range, 1.0-8.7 years). Follow-up was longer than 3 years in 6 patients. RESULTS: Of 47 lower limbs (in 34 patients) included in the analysis, 15 were managed with IMPL. There were no significant between-group differences at baseline. Surgery was followed in all limbs by significant decreases in kinematic hip flexion and in the Gillette Gait Index. In the IMPL group, significant improvements occurred in clinical hip flexion deformity, walking speed, and step length. The improvement in kinematic hip extension was not significantly different between the two groups. Crouch gait recurred in 3 (8%) patients. DISCUSSION: The improvement in kinematic hip extension in terminal stance was not significantly influenced by IMPL but was, instead, chiefly dependent on improved knee extension and on the position of the ground reaction vector after SEMLS. IMPL remains indicated only when the clinical hip flexion deformity exceeds 20°. LEVEL OF EVIDENCE: IV, retrospective study.

One-stage hip reconstruction in children with cerebral palsy: long-term results at skeletal maturity.

PURPOSE: Hip subluxation is common in children with cerebral palsy (CP). Surgery is indicated in case of pain or progressive increase of Reimers index on radiographs. Peri-iliac osteotomy combined with femoral osteotomy is one of the numerous operative techniques available, but results at skeletal maturity remain unclear. The purpose of this radiological study was to report the long-term results of this procedure. MATERIALS AND METHODS: Twenty hips in 20 children were retrospectively evaluated at skeletal maturity. Mean age at surgery was 8.1 years and follow-up averaged 9.1 years. All patients underwent Dega acetabuloplasty, soft-tissue release and femoral-shortening varus derotation osteotomy without open reduction. Reimers index, acetabular angle (AA) and neck-shaft angle (NSA) were compared on preoperative, postoperative and latest follow-up radiographs. RESULTS: Dega osteotomy significantly improved the AA and the correction remained stable at maturity. The NSA significantly decreased postoperatively (153°-115°), but recurrence of the valgus deformity (130°) of the proximal femur was observed at maturity. Consequently, Reimers index followed the same evolution. No case of osteonecrosis was reported but one hip dislocated and one subluxated during follow-up. CONCLUSION: Progressive recurrence of the valgus deformity of the proximal femur, attributable to adductors spasticity and gluteus medius weakness, led to a significant increase in the Reimers index. However, hip coverage remained >70 % at maturity in 90 % of the hips. This one-stage procedure without hip dislocation efficaciously corrected acetabulum dysplasia and successfully treated neurological hips in CP patients. LEVEL OF EVIDENCE IV: retrospective study.

Efficacy and late complications of percutaneous epiphysiodesis with transphyseal screws.

Percutaneous epiphysiodesis using transphyseal screws (PETS) has been developed for the treatment of lower limb discrepancies with the aim of replacing traditional open procedures. The goal of this study was to evaluate its efficacy and safety at skeletal maturity. A total of 45 consecutive patients with a mean skeletal age of 12.7 years (8.5 to 15) were included and followed until maturity. The mean efficacy of the femoral epiphysiodesis was 35% (14% to 87%) at six months and 66% (21% to 100%) at maturity. The mean efficacy of the tibial epiphysiodesis was 46% (18% to 73%) at six months and 66% (25% to 100%) at maturity. In both groups of patients the under-correction was significantly reduced between six months post-operatively and skeletal maturity. The overall rate of revision was 18% (eight patients), and seven of these revisions (87.5%) involved the tibia. This series showed that use of the PETS technique in the femur was safe, but that its use in the tibia was associated with a significant rate of complications, including a valgus deformity in nine patients (20%), leading us to abandon it in the tibia. The arrest of growth was delayed and the final loss of growth at maturity was only 66% of that predicted pre-operatively. This should be taken into account in the pre-operative planning.

Fixator-assisted medial tibial plateau elevation to treat severe Blount's disease: outcomes at maturity.

INTRODUCTION: Severe forms of Blount's disease may be associated with medial tibial plateau (MTP) depression. Management should then take account of joint congruence, laxity, limb axis, torsional abnomality, leg length discrepancy (LLD) and eventual recurrence history. PATIENTS AND METHODS: Eight knees (six patients) were managed in a single step comprising MTP elevation osteotomy, lateral epiphysiodesis and proximal tibia osteotomy to correct varus and rotational deformity. Fixation was achieved using an Ilizarov external fixator. Mean age was 10.5 years. Mean hip-knee-ankle (HKA) angle was 151°; distal femoral varus, 94°; metaphyseal-diaphyseal angle (MDA), 27°; and angle of depression of the medial tibial plateau (ADMTP), 42°. Predicted residual proximal tibial growth was 2.6 cm. RESULTS: At a mean 48 months' follow-up, results were good in six cases, medium in one and poor (due to incomplete lateral epiphysiodesis) in one. Mean lateral tibial torsion was 9° and final LLD 11 mm. Weight-bearing was resumed at 2 months, and the fixator was removed at 5.5 months postoperatively. At end of follow-up, mean HKA angle was 179.6°, MDA 7.3° and ADMTP 5.4°. DISCUSSION: This technically demanding procedure gave satisfactory results in terms of axes and congruence; longer term assessment remains needed. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Upper extremity kinematics analysis in obstetrical brachial plexus palsy.

INTRODUCTION: Several recent studies demonstrate that upper extremities kinematics analysis is in increasing use to assist clinical practice. We describe an upper limb kinematics analysis protocol that was first applied to a group of healthy children (to obtain normative data), and subsequently, to a child presenting with obstetrical brachial plexus palsy (OBPP) before and after surgical treatment. MATERIALS AND METHODS: The protocol is based on two very simple tasks. Reflective markers are placed on the studied segments, and optoelectronic cameras three-dimensionally record the position of the markers during the course of movement. The data, collected by a Vicon system (Oxford Metrics Ltd., Oxford, UK), are analyzed by a dedicated software; this software provides coefficient of multiple correlation (CMC) for the comparison of different kinematics curves and motion amplitudes. A CMC above 0.95 was considered to be excellent, between 0.85 and 0.95 was good, and below 0.85 was poor. Twelve healthy children, average age 9.7 years (from 7 to 14 years), were analyzed. A 7-year-old patient presenting left OBPP was similarly analyzed, pre- and postoperatively, after a lateral rotation osteotomy of the humerus. RESULTS: The analysis of the 12 healthy children established a kinematics corridor for each task and each angle considered. Analysis of the pathological patient revealed kinematics anomalies during movement which went undetected at simple clinical examination. CMC analysis after treatment showed improvement of all movements around the shoulder, going from "poor" preoperatively to "excellent" postoperatively. Amplitudes analysis similarly demonstrated postoperative improvement, which increased from 28 to 67% according to the rotations considered, around the shoulder and elbow. The interest in these results should be confirmed by studies in a larger number of patients. DISCUSSION: Upper extremity kinematics analysis is increasingly utilized in current clinical practice. Although many problems occur because of the non-cyclical and non-automatic nature of movement, review of the literature and our preliminary results show that reproducibility is satisfactory. Interest in our work arises from helping develop a preoperative evaluation tool (providing a more global view of abnormalities) as well as a postoperative assessment one (for the quantification of movement gains obtained by surgery after humeral osteotomy). LEVEL OF EVIDENCE: Level IV. Diagnostic retrospective study.

[Macrodactyly]. / Macrodactylie.

There are two types of congenital enlargement of the finger. In one type, the finger is enlarged as part of a syndrome or because of a tumor or a malformation. In the other, the finger is enlarged as an isolated anomaly called "true macrodactyly", with an abundance of fat mainly on the palmar side of the finger. This condition is a rare congenital malformation and the etiology is unknow. The enlarged portion of the finger or the hand can be in a distribution of a major peripheral nerve, most often the median nerve. This condition is called nerve territory-oriented macrodactyly. Macrodactyly can be static, present at birth and does not increase disproportionately with growth, or progressive with a disproportionate growth of the digit. Treatments are difficult and challenging. The goals of operative treatments are: to control the growth in children, mainly with epiphysiodesis; to reduce the size of the finger with resection of skin and subcutaneous tissue with occasionally recession osteotomy, angulation osteotomy and arthrodesis; amputation in severe progressive macrodactyly. Parents should be informed of the potentiel number of operations necessary and of the limitation of function.

[How to determine the upper level of instrumentation in thoracic adolescent idiopathic scoliosis: a prospective study of 103 patients]. / Planification du niveau supérieur d'arthrodèse dans les scolioses idiopathiques thoraciques de l'adolescent: étude prospective de 103 cas.

PURPOSE OF THE STUDY: Determining the level of fusion remains a highly debated topic in adolescent isiopathic scoliosis. The King and Lenke classifications are used, but have their limitations, particularly the weak interobserver reproducibility. We describe the method we use which is independent of the anatomic classification, based on the predictable reduction of the different curvatures. The goal is to achieve good balance of T1 and the shoulders and reestablish spinal balance in the frontal and sagittal planes. The purpose of this work was to assess the midterm results of this strategy for determining the upper level of instrumentation. MATERIAL AND METHODS: The series included 103 adolescents who underwent surgery for idiopathic thoracic scoliosis using a posterior segmental instrumentation. The upper level of fusion was determined by analyzing the rigidity of the proximal curvature and the inclination of T1 and the shoulder. X-rays (preop, postop, last follow-up) were digitalized for computer processing. Comparisons were made with the t test for paired series. RESULTS: Mean age at surgery was 15.2+/-1.7 years (range 10.8-19.3). Mean follow-up was 30.2 months. The clavicular angle and T1 inclination were improved significantly, both for the unique thoracic curvatures and for double thoracic curvatures. No correlation could be found between T1 inclination and shoulder balance. At last follow-up, 86.5% of the patients satisfied all balance criteria. DISCUSSION: The results of our method, which was carried out fully in 97% of patients, are encouraging and show that systematic instrumentation of the entire proximal curvature is not warranted for double thoracic curvatures. The long-term consequences for the residual T1 inclination remain to be assessed.

[Laboratory studies in pediatric bone and joint infections]. / Marqueurs de l'inflammation et infection ostéoarticulaire.

The diagnosis of acute osteomyelitis and septic arthritis is a clinical one. Acute-phase reactants, such as white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are useful to help the clinicians at the time of initial diagnosis. The WBC count may be normal in up to 80 % of cases and it is not a reliable indicator. The ESR is elevated in 80 % of cases. CRP is elevated more than 80 % of cases. CRP rises rapidly within 48 hours of admission and returns to normal within a week after appropriate therapy. Its rapid kinetics is useful for follow-up of the response treatment. Patients who require surgical drainage procedures have prolonged time to normalization of CRP. PCT is a useful specific marker for predicting severe infection but its sensibility to detect bone and joint infections seems to be low.

[Finger trauma in children: errors to be avoided]. / Les traumatismes du doigt chez l'enfant: les erreurs à éviter.

Two types of digital trauma are often met: in the young child, it is generally about a fingertip crushing by a door. In the event a of nail bed wound, the child will have to be addressed for a surgical treatment, the absence of a correct treatment being able to be responsible for after-effect. In the older child, the trauma is generally indirect during a sports activity or a game. Radiography often shows a fracture of phalanx epiphysal plate. The treatment is generally orthopaedic: simple immobilization if the fracture is not displaced, reduction and immobilization in the event of displaced fracture.

Thenar flap for severe finger tip injuries in children.

Twelve children aged between 18 months and 11 years old who had sustained a severe fingertip amputation with total or subtotal pulp loss were treated with a distal-based thenar flap. The injuries were palmar oblique amputations or avulsion injuries involving the pulp and the nail bed. The pedicles of the thenar flaps were divided after 18 to 25 days and none suffered any necrosis. At the final follow-up, no interphalangeal joint contractures were found, the average two point discrimination was 5mm, the thenar scar was asymptomatic and the subcutaneous tissue of the thenar flap was providing sufficient bulk to produce a rounded contour, like a normal fingertip. The thenar flap is a useful technique for use with severe fingertip injuries when local flaps cannot provide enough soft tissue and replantation is not possible.

[Surgical treatment of a femoral agenesis: a case report]. / Traitement chirurgical d'une agénésie fémorale sévère chez l'adulte: à propos d'un cas.

We report a case of severe femoral agenesia in an adult and propose a new surgical approach facilitating prosthesis fitting. The procedure involves insertion of a total hip arthroplasty, arthrodesis of the knee and amputation of the foot. The final prosthesis fits on the crural area with weight bearing on the ischiatic region, the lesser pelvis, and the articulated knee. Outcome was satisfactory at one year in our patient. Other surgical alternatives are presented.

[Treatment of phalangeal neck fractures in children: technical suggestion]. / Traitement des fractures des cols des phalanges à grand déplacement chez l'enfant: proposition technique.

INTRODUCTION: Phalangeal neck fractures in children are not very frequent lesions. The purpose of this study is to bring out results of treatment of these fractures and provide an adequate procedure. PATIENTS AND METHODS: Twenty-three patients with 24 phalangeal neck fractures were reviewed. Seventeen boys and six girls with a mean age of 7 years and 6 months. Open wound fractures were noted in 13 cases. A direct trauma was noted in 17 cases and an indirect trauma in seven cases. Treatment consisted of a closed reduction and cast immobilization in four cases. A closed reduction and percutaneous pinning in seven cases. Open reduction and osteosynthesis in 13 cases. RESULTS: All patients were reviewed with a mean follow-up of 16 months and functional results were evaluated by measuring the Total Active Motion. Fractures treated orthopedically (4) gave Good results; percutaneous pinning (seven cases) gave one Poor, one Fair and five Good results; open reduction and osteosynthesis gave zero Good, six Fair and seven Poor results. Phalangeal head osteonecrosis was noted in four cases treated by open reduction. DISCUSSION: Closed reduction and percutaneous treatment of these fractures give the best functional results. This study demonstrates that open surgical reduction of these fractures leads to phalangeal head osteonecrosis and poor functional result. We propose here a technical improvement of percutaneous reduction with intrafocal pining and osteosynthesis. CONCLUSION: This technical improvement of percutaneous reduction and pinning allow to combine the advantages of a closed reduction and to avoid distal epiphyseal necrosis.

[The medial saphenous hetero (cross leg) flap in coverage of soft tissue defects of the leg and foot]. / Place du lambeau saphène médial hétéro jambier (cross-leg) dans la couverture des pertes de substance de la jambe et du pied.

PURPOSE OF THE STUDY: Reconstruction of large areas of soft tissue defects of the lower limb is a major challenge, particularly when the zone involves the lower part of the leg and the foot. The cross-leg flap can be a reliable alternative to free flaps, both in adults and children. We analyzed our experience in a retrospective series of 26 patients who underwent a standardize surgical procedure. MATERIAL AND METHODS: Twenty-six cross-leg flap procedures were performed between 1984 and 2000 using the same technique. Mean patient age was 32 years (range 7-67 years). All patients were trauma victims. Mean delay from trauma to flap reconstruction was 2.5 years (range 18 days-16 years). A free flap or loco-regional flap for coverage had been unsuccessful in 19 patients. The zones involved were: leg (n=7), anterior ankle area (n=3), malleolar area (n=2), dorsal aspect of the foot (n=1), heal (n=11, including 4 in an exclusively non-weight-bearing area). Mean patient follow-up was 3 years (1-10 years). The same surgical technique with external fixation was used for all patients. The flap was harvested according to a standard technique with ratios ranging from 3: 1 to 4: 1. The donor site and the flap pedicle were covered with a thin skin flap, at least during the first operative time. During the first operative time, the recipient site was resected to the exact size of the flap, the remaining coverage was achieved during the weaning process using part of the flap pedicle. Weaning was achieved after a mean 27 days (21-38 days). RESULTS: Complete flap necrosis occurred in one case and partial necrosis in six. Punctual necrosis was observed in five cases requiring revision surgery or local care. One abscess of the donor site occurred two years after flap reconstruction. Coverage was satisfactory for leg and ankle reconstructions, with no recurrent ulcerations or hyperkeratosis at last follow-up. A satisfactory esthetic aspect was achieved in all cases. For foot reconstructions, ulcerations or hyperkeratosis of the plantar skin-flap junction was observed in five cases. All of the patients were however able to wear normal shoes and felt there had been an improvement after surgery. DISCUSSION: The cross-leg flap procedure should, in our opinion, be used in three situations. i) After failure of other techniques: results are very reliable for salvage procedures; 19 of our 26 patients had had failed free or loco-regional flap procedures prior to the cross-leg flap. ii) The reconstruction is large and blood supply contraindicates a free flap procedure (only one intact vascular axis). iii) The entire heal area to be reconstructed would be insufficiently covered by a free flap. Most of the long-term problems are related to heal coverage in weight-bearing areas.

Systematic pinning of displaced extension-type supracondylar fractures of the humerus in children. A prospective study of 116 consecutive patients.

We report the results of 116 consecutive displaced extension supracondylar fractures of the elbow in children treated during the first two years after the introduction of the following protocol; closed reduction under general anaesthesia with fluoroscopic control and lateral percutaneous pinning using two parallel pins or, when closed reduction failed, open reduction and internal fixation by cross-pinning. Eight patients were lost to follow-up during the first postoperative year. The mean follow-up for the remaining 108 was 27.9 months (12 to 47, median 26.5). At the final follow-up, using Flynn's overall modified classification, the clinical result was considered to be excellent in 99 patients (91.6%), good in five (4.6%) and poor in four (3.7%). All the poor results were due to a poor cosmetic result, but had good or excellent function. Technical error in the initial management of these four cases was thought to be the cause of the poor results. The protocol described resulted in good or excellent results in 96% of our patients, providing a safe and efficient treatment for displaced supracondylar fractures of the humerus even in less experienced hands.

Repair of the flexor pollicis longus tendon in children.

This is a retrospective study of primary repairs of flexor pollicis longus in 16 children under 15 years of age. Patients with injuries to the median or ulnar nerve at the wrist, crush injuries, skin loss or fracture were excluded. Repairs were carried out within 24 hours using a modified Kessler technique. The mean follow-up was for two years. The final results were evaluated using the criteria of Buck-Gramko and Tubiana. They were good or excellent in all except one patient who had a secondary tendon rupture. When compared with the non-injured thumb, however, there was a significant decrease in active interphalangeal flexion (> 30 degrees) in one-third of cases. A new method of assessment is proposed for the recovery of function of the flexor pollicis tendon which is more suitable for children. Postoperative immobilisation using a short splint had a negative effect on outcome. The zone of injury, an early mobilisation programme or concurrent injury to the digital nerve had no significant effect on the final result.

[Buruli ulcer: an exported pathology]. / Ulcère de Buruli: une pathologie d'exportation.

CASE REPORT: A nine-year-old boy from the Ivory Coast was admitted to hospital because of extremely serious Buruli ulcers. CONCLUSION: Surgery is the only treatment available. Moreover, the surgical excision has to be wide; both open and closed wounds have to be removed to give significant improvements.

The unstable patella in children.

The authors reviewed 102 unstable patellas which had been observed and treated from 1964 to 1990. They were divided according to whether they suffered from traumatic dislocations, recurrent dislocations or malformative instability. The clinical findings were the major stage of the check up. In the field of imaging, standard X-rays had to be performed in all cases. MRI was of interest in the congenital dislocations, in order to thoroughly investigate the soft tissue anomalies. Two types were described: Type 1 was observed in children with joint laxity, but without major X-ray anomalies; Type 2, a major femoropatellar dysplasia could be formed with some bone deformity. The latter was observed in the malformative instability. Four different surgical procedures have been used, from the release of the retinacula of patella to the medial displacement of the patellar tendon or the tibial tuberosity. This study emphasises the concept of a true development dysplasia of patella (DDP) which can gather the different varieties of the instability of patella.

Flexor tendon injuries in children: factors influencing prognosis.

We reviewed a series of 44 children with 58 fingers involved, 21 of them occurring in the digital canal. The core stitch was performed according to the Kessler modified technique. The mean follow-up at the time of review was 3 years. The return of total active motion (TAM) in the interphalangeal joints was evaluated with the Strickland formula. Results were excellent in 84%, good in 5%, fair in 2%, and poor in 9%. Influencing factors were children younger than 5 years, lesions in zone II, both tendon injuries in the digital canal, and the type of immobilization (below-elbow splint). Rupture occurred in 9%, especially in the very young children with a short postoperative immobilization. Variables such as the early-mobilization program, the length of the postoperative immobilization period, or concurrent digital nerve injury had no significant effect on the final result.