Chronic recurrent multifocal osteomyelitis (C.R.M.O.). A case report and review of literature.

The case of an 8-year-old boy presenting two episodes of osteomyelitis of the left and right tibial diaphysis is reported. The recurrent course, the negative cultures and the symmetrical aspect of the lesions suggest the diagnosis of recurrent multifocal osteomyelitis. The location of the lesions at the middle of the diaphysis and the histological finding of predominant bone necrosis are unusual.

Cause and prevention of osteochondritis in congenital dislocation of the hip.

All treatment modalities of congenital displacement of the hip (CDH) bear the risk of ischemic necrosis at the proximal femoral epiphysis. The causes of ischemic necrosis were investigated in a review of the literature and personal experience with CDH patients during the past 30 years. Compression of articular cartilage, caused by an increase in intraarticular pressure, has been implicated as the mechanism of osteochondritis. Muscle spasm, pressure on posterior circumflex vessels, and compromised pericephalic microcirculation in the newborn have been demonstrated to increase intraarticular pressure. The most dangerous causative factors include forced reduction under general anesthesia, spica cast immobilization of the hips in the Lorenz or Lange position, insufficient continuous prereduction traction, and splints or braces that are either too rigid or that force the hip into an extreme position. An intertrochanteric varus osteotomy can also lead to ischemic necrosis when performed at the time of reduction. Preventive measures include sufficient continuous traction, casting in a moderate position, and bracing that allows active movement. None of these measures constitute a guarantee against necrosis, but they will lessen the incidence and severity of involvement.

Skin elastic fiber pathology and idiopathic scoliosis.

An antomic study of skin elastic fibers coupled with a histochemical and ultrastructural study of one peripheral muscle sample was performed in 34 patients with idiopathic scoliosis. Twenty-eight of them had an elastopathy resulting in rupture or disparity between the dermis elastic fibers. The muscle histoenzymologic study showed that 17 of the patients also had an abnormal predominance of type I muscle fibers. These data led to our discussion of the role of elastic tissue abnormalities in the genesis of early or severe idiopathic scolioses.

[Acetabuloplasty by pedicled transfer of the iliac crest apophysis in the dog]. / Azetabulumplastiken durch gestielten Transfer der Beckenkammapophyse beim Hund.

Appositional incremental acetabuloplasty using a self growing iliac crest graft pedicle on its epipyseal vessels was performed in 54 puppies 3 months old. Remodeling an adaptation to the shape of the acetabulum is excellent in most of the cases, issuing into a spherical composite cavity. Persistance of a hyaline cartilage is noted until the end of the first years, but long term morphological transmission electronmicroscopy studies demonstrate a progressive transformation into fibrocartilage. This experimental study demonstrates the possibility to use remodeling and growth properties of a pedicled iliac crest, transplanted as an iland flap on the extraarticular acetabular roof. This new surgical technique can be proposed for the care of difficult dysplastic hips in children.

Pedicled scapular apophysis transplantation. Growing grafts studied in dogs.

Twenty-eight immature dogs, divided into three groups, have been studied to determine the possibilities of pedicled epiphyseal transplantation from a rarely used donor site area, the scapula. One group of 8 immature dogs were studied anatomically using India ink and Batson's compound injection methods. We identified the vascular pattern of the diaphyseal portion of the graft, consisting of the lateral crest or border of the scapula. In two groups of 10 immature dogs, this area was used as a pedicled island graft to rebuild the semiresected or totally resected proximal humerus. There were marked differences between these two groups on the basis of morphologic, histologic, histochemical and electron microscopic aspects of the samples. Preservation of normal growth appeared to be directly related to the compressive forces applied to the graft. Preservation of the cartilage was also related to the biomechanical situation; fibrocartilage and signs of arthrosis were noted 1 year after the operation in several animals whose humeri had been fully subjected to normal stresses. Both the diaphyseal and epiphyseal areas had increased one- to fivefold in volume, but longitudinal growth was markedly deficient.

[Biology of micro-vascularized cartilaginous transplantation in the growing dog]. / Biologie des transplantations cartilagineuses micro-vascularisées chez le chien en croissance.

Epiphyseal bone transplantations including growth area have been extensively studied experimentally in different animals and applied in children for several decades. Results were unpredictable and the amount of growth obtained with the graft could get 50 per cent of the normal. Development of microsurgical techniques has determined new possibilities of epiphyseal transfer with the respect of the epiphyseal vascularization. Growth plate germinal cell division is directly related to the epiphyseal vascular respect. In a large multifacetted program we could successively determine the vascular patterns of the donor site areas and then utilized different grafts in some experimental situations reproducing the clinical pathology in children, like hip dysplasia or epiphyseal defects after resection for tumor or infection. Results demonstrate that the main problem, in epiphyseal transplantation, is not vascular but mechanical. Further studies have to be done in this direction.

Ultrastructural aspects of nerves, bones, and vessels in hereditary sensory neuropathy.

This study concerns two children, from the same otherwise normal family, presenting progressive spontaneous amputations of the limbs, suggesting peripheral hereditary sensory neuropathy. Samples from the distal nerves and vessels and the distal tibial epiphyses were examined ultrastructurally. The nerves showed signs of degeneration, and a typical bone necrosis, without osteoclasts, was observed in the 2 cm margin of the samples. Simultaneous modifications of the vessels suggest a neurally initiated vascular reflex resulting in bone destruction. Theories that might explain the observations are discussed.

[Arrangement of collagen fibers in the epiphyses and metaphyses of long bones in vertebrates]. / Disposition des fibres de collagène dans l'epiphyse et la métaphyse des os longs de vertébrés.

The arrangement of collagene fibers in bone epiphyses and mataphyses form various species of reptiles and mammals was studied with a polarized light microscope and with a scanning electron microscope. In spite of the variety of shape observed in the long bone extremities of different species, the collagenic fibers arrangement in the bone epiphyses and metaphyses appeared constant. Even in reptiles known to lack a growth plate, the metaphyseal and epiphyseal fiber patterns evoked those observed in mammals. A common fiber pattern may therefore be proposed which allows the coexistence of two apparently incompatible functions: growth, that induces an increased fragility at the epiphyseo-metaphyseal junction as opposed to mechanical support, which has to cope with load and traction forces at the same junctional site.

Epiphyseal vascularization during growth: the upper limb.

Sixty fetal, newborn and child cadavers were injected with India ink and plastic material (Batson's technique) via the subclavian artery. The arterial and capillary intracartilaginous and intraosseous networks of the physes of the long bones of the upper limb were then studied by microdissection of the vascular sources and serial epiphyseal sections in different planes. Already present in the third week of fetal life and present all during the rest of life, this circulation plays a fundamental role not only in the ossification of the epiphyseal cartilage but also in the trophicity of the bone that supports the cartilaginous articular surfaces. Like those of the lower limb, the epiphyses of the upper limb present a typical vascular pattern consisting of three entries, with the exception however of the inferior extremity of the ulna.

Legg-Calvé-Perthes disease. Histochemical and ultrastructural observations of the epiphyseal cartilage and physis.

UNLABELLED: Biopsy specimens of the lateral aspect of the femoral head and neck were obtained from five children with Legg-Calvé-Perthes disease and were studied using histochemistry and electron microscopy. Beneath the normal articular cartilage there was a thick zone of hyaline (epiphyseal) cartilage containing sharply demarcated areas of hypercellular and fibrillated cartilage with prominent blood vessels. The fibrillated cartilage was strongly positive to alcian blue, weakly positive to periodic acid-Schiff, and positive to aniline blue. The interterritorial matrix in the hypercellular areas was weakly positive to both alcian blue and periodic acid-Schiff. Ultrastructural examination of these areas revealed many irregularly oriented large collagen fibrils and variable amounts of proteoglycan granules. These results suggest that in the fibrillar areas there are: (1) a high proteoglycan content, (2) a decrease in structural glycoproteins, and (3) a different size of collagen fibrils from that of normal epiphyseal cartilage. The hypercellular areas had a decrease in proteoglycans, glycoproteins, and collagen. The lateral physeal margin was often irregular, with a marked reduction of collagen and proteoglycan granules, and contained numerous large lipid inclusions. CLINICAL RELEVANCE: The abnormal areas in the epiphyseal cartilage of patients with Legg-Calvé-Perthes disease have different histochemical and structural properties from normal cartilage and from fibrocartilage. This suggests that the disease could be a localized expression of a generalized, transient disorder of epiphyseal cartilage that is responsible for delayed skeletal maturation. The cartilage lesions are similar to those seen in the vertebral plates in patients with juvenile kyphosis. Whether the epiphyseal cartilage abnormalities are primary or are secondary to ischemia remains uncertain; however, it appears that the collapse and necrosis of the femoral head could result from the breakdown and disorganization of the matrix of the epiphyseal cartilage, followed by abnormal ossification.

[Acetabuloplasty using pedicle graft of the iliac crest epiphysis in puppies]. / Acétabuloplastie par greffon pédiculé d'épiphyse de crête iliaque chez le chien en croissance.

Pedicled iliac crest epiphysis transplantation was performed after resection of the outer portion of the acetabulum in 30 puppies 3 months old. The best joint congruency was obtained when using a vertical pedicled graft, the surface of which developed into normal articular cartilage through metaplasia, and presented normal cartilage growth by means of conservation of the epiphyseal vessels. The results of this experiment enable the authors to propose a new surgical technique in the treatment of certain difficult dysplastic conditions in the hip.

[Pneumoblastoma in children. Apropos of 2 cases]. / Le pneumoblastome chez l'enfant. A propos de 2 observations.

Pulmonary blastoma is an exceedingly rare primary neoplasm in the paediatric age group. Pre-operative diagnosis is impossible because of its lack of specificity in clinical and radiological signs. The only diagnosis is the histopathological one. It is a malignant tumor capable of metastasis with a poor prognosis. The best method of treatment is still unknown but at the present time, the only survivals are the result of a complete and early surgical excision. The authors report 2 paediatric cases which have been observed at the hospital of Montpellier (France) for a 20 years period. They try to determine why children's pulmonary blastoma is slightly different from the adults one. They ask the question of histogenesis.