[Osteochondritis dissecans of the femoral condyles: report of 892 cases]. / L'ostéochondrite disséquante des condyles fémoraux.

PURPOSE OF THE STUDY: Osteochondritis rarely involves the femoral condyles. Discovery in this localization raises several questions concerning the nature of the articular cartilage, the potential for spontaneous healing, and, in the event of a free fragment, the outcome after its loss or repair. MATERIAL AND METHODS: This multicentric study included 892 pediatric and adult cases, the cutoff between two series being defined by fusion of the inferior growth plate. We excluded medical or surgical osteochondritis, cases involving the patella, osteochondral fractures, juvenile polyosteochondrosis, adult osteonecrosis, and osteochondritis beginning after the age of 50 years. RESULTS: Mean age at diagnosis was 16.5 years. Mean age at treatment onset was 22 years. Pain was the predominant symptom. 80% of cases were unilateral and 70% involved the medial condyle. The anatomic lesions were different in adults, showing more advanced degradation. At diagnosis, Bedouelle stages Ia and IIb constituted 80% of the cases observed among children while in adults, 66% were Bedouelle stages IIb to IV. Outcome was very good for the majority of children with Hughston clinical stage 4 while half of the x-rays were Hughston stage 3 and 4. There were thus a large percentage of children with abnormal xrays whose disease history was not yet terminated. In the adult series, the percentages of Hughston 3 and 4 was about the same as clinically. The x-rays were rarely perfectly normal since half of the clinical stage 3 patients were noted in stage 4. An abnormal x-ray with a very good clinical presentation was observed in a very large proportion of patients. DISCUSSION: It is difficult to interpret the plain x-ray and identify patients with a potentially unfavorable prognosis. We defined three radiographic classes: defect, nodule and empty notch. The Bedouelle classification uses information from all available explorations, particularly MRI and arthroscopy. Numerous therapeutic methods are used. Interruption of sports activities is the first intention treatment for children. Data in the literature and the findings of this symposium do not demonstrate any beneficial effect of immobilization on healing compared with simple abstention from sports activities. Transchondral perforation is a simple operation with low morbidity. In 85% of cases, it was used for lesions with an intact joint cartilage considered stable in 96% of cases. Healing was achieved in six months for 48% if the growth plate had not fused. The fragment was fixed in 43% of the cases with a loose cartilage fragment. Outcome was fair but degraded with the state of the joint cartilage and thus the stability of the fragment. Fixation must stabilize the fragment but not prevent further consolidation via osteogenesis. This is why deep perforations are drilled beyond the ossified area and additional osteochondral grafts are used. The Wagner operation gives less satisfactory results than more complicated procedures. Removal of a sequestrum is a simple, minimally invasive procedure with an uneventful postoperative period, but in the long term it favors osteoarthritic degradation, especially when performed in adults. Mosaic grafts give good mid term results. Morbidity is low especially if the grafts are harvested above the notch. The question of chondrolysis around the grafts was beyond the scope of this study. Chondrocyte grafting is difficult to accomplish and is expensive. The mid term results are good for large lesions. Osteotomy is logical only in the event of early stage osteoarthritic degradation. DECISION ALGORITHM IN CHILDREN AND ADOLESCENTS: If the plain x-ray reveals a defect (class I), simple interruption of sports activities should be proposed. Two situations can then develop. First, in a certain number of patients, the pain disappears as the defective zone ossifies progressively. Complete cure is frequent before the age of 12 years. In the second situation, the knee remains painful and the x-ray does not change or worsens to a class II nodular formation. In this case an MRI must be obtained to determine whether the joint cartilage is normal. There are two possibilities. First, the osteochondral fragment is viable and most probably will become completely re-integrated, particularly if the lesion is far from the growth plate. Necrosis is the other possibility. Transchondral perforations are needed in this case. If on the contrary the cartilage is altered, there is little hope for spontaneous cure. Arthroscopy may be needed to complete the exploration. Fragments, especially if there is a large surface area, must be fixed. Perforations to favor revascularization are certainly useful here. In the last situation (class III), the fragment wobbles on a thin attachment or has already fallen into the joint space. This is the type of problem generally observed in adults. The decision algorithm in adults is the same as in children for the rare nodular aspects (class II). There could be a discussion between transcartilage perforation and fixation. If there are a large number of fragments, fixation may not be fully successful and the lesion might be considered class III. For class III lesions, three operations can be used: removal of the sequestrum, mosaic bone-cartilage grafts, or autologous chondrocyte grafts. At the same follow-up, mosaic grafts give better results than excision of sequestra. It may be useful to remove sequestra in a limited number of situations: if there is just a small area of osteochondritis, the lesion is old and partially healed, or the zone is non weight-bearing. For other lesions, we favor mosaic grafts. We still do not have enough follow-up to assess the long-term outcome with these mosaic grafts, but simple excision clearly favors osteoarthritic degradation. Can chondrocytes grafts be compared with mosaic grafts? Chondrocyte grafts have been used for very large lesions and have given results similar to mosaic grafts. It might also be possible to combine fixation of a loose fragment and a mosaic graft. LESSONS FROM THIS STUDY: 1) The prognosis of osteochondritis is better before than after fusion of the growth plate but the lesion does not always heal in children. 2) Presence of osteochondritis requires complementary anatomic and functional exploration to determine the stability and the vitality of the fragment. 3) Attention must be taken to perform transchondral perforations early enough, particularly in children. 4) Screw fixation is not always sufficient. The trophicity of the fragment and its blood supply must be improved. 5) Mosaic grafts are preferable to excision of the fragment. 6) Chondrocyte grafts will be more widely used in the future.

[Retrograde locked nailing of humeral shaft fractures: a prospective study of 58 cases]. / Traitement des fractures récentes de la diaphyse humérale par enclouage centromédullaire verrouillé rétrograde: une étude prospective de 58 cas.

PURPOSE OF THE STUDY: Appropriate treatment for humeral shaft fractures remains a debated issue. Among the classical osteosynthesis techniques proposed, closed nailing was adapted to the humerus rather late, using the anterograde method. Use of retrograde nailing, which spares the rotator cuff, is more recent. The purpose of this study was to report outcome in 58 humeral shaft fractures in adults treated using the universal humeral nail between January 2000 and December 2003. MATERIAL AND METHODS: This work was limited to recent shaft fractures in adults with non-pathological bones. The fractures included were all situated between the insertion of the pectoralis major and a point situated 2 cm above the apex of the olecraneum fossa. The series included 58 patients with 58 humeral shaft fractures. All fractures were closed except four (Gustilo type I and II). Two patients presented preoperative radial paralysis which was not considered to be a contraindication for retrograde locking nailing. The paralysis recovered in both patients, after neurolysis performed during the nailing procedure in one. Osteosynthesis was performed without opening the fracture focus under fluoroscopic control using a static locking nail inserted retrograde in patients in the supine position. RESULTS: There were two early deaths unrelated to the method. Healing was obtained in the surviving patients within fifteen weeks on average. Bone healing was primary in 53 patients and after secondary compression in three. At last follow-up, shoulder motion was normal in 88% of patients and elbow motion in 91%. The Rommens functional score was good in 84%. Complications included three cases of spontaneously regressive postoperative radial paralysis, three cases of reflex dystrophy including two which regressed, and two cases of humeral palette fracture requiring surgical osteosynthesis. The proximal screws were removed in six patients because of pain or migration. To date, implants have been removed in three patients without problem. There were no infections. CONCLUSION: Retrograde insertion of this nail facilitates treatment of humeral shaft fractures by allowing immediate joint motion and the advantages of closed reduction: no infection, no late bone healing requiring conversion to another method of fixation. The residual technical problems concern proximal nailing and nail introduction.

[Comparison of the medial femorotibial joint space before and immediately after meniscectomy]. / Hauteur radiologique de l'interligne fémoro-tibial médial avant et immédiatement après méniscectomie.

PURPOSE OF THE STUDY: The purpose of this prospective study was to develop and evaluate a method for measuring the femorotibial joint space and to assess the effect of meniscectomy. MATERIAL AND METHODS: This study was conducted in a consecutive series of 36 patients undergoing arthroscopic meniscectomy for lesions of the medial meniscus on a stable knee. The height of the joint space was measured on x-rays taken in the morning before the operation then ten days later. X-rays were obtained for both knees in complete extension and in the 30 degrees flexion position. The height of the joint space was measured on the digital version of the x-rays midway between the vertical tangents of the posterior limits of the medial condyle. RESULTS: Readings were not reader dependent and demonstrated no significant difference between the pre and postmeniscectomy height of the medial femorotibial space (30 degrees flexion view, 5.2 +/- 1 and 5.2 +/- 1 before meniscectomy for reader 1 and 5.2 +/- 1 and 5.2 +/- 1 for reader 2 (p=0.05 for Student-Fisher test for paired values). The heights measured by the two readers were correlated (correlation coefficient test). DISCUSSION: The height of the medial femorotibial joint space can be measured reproductibly on plain x-rays of the knee in the standard flexion position. We were unable to demonstrate any significant difference in joint space between measures taken before and after meniscectomy.

Perceptions of orthodontic appliances among grade seven students and their parents.

A survey of 468 Grade Seven students and 437 parents in the North Brisbane region was undertaken to determine perceptions of orthodontic appliances. Based on responses to statements on the survey, a Perception Score was created for both students and parents in relation to both fixed and removable appliances. Both students and parents had more negative perceptions of fixed appliances than of removable appliances. Fixed appliances were perceived to attract more teasing, to cause more problems in the maintenance of oral hygiene and to be more painful than a removable plate. Respondents also felt that children would have to be more careful about what they eat when wearing fixed appliances. Approximately forty per cent of students and parents did not know whether teeth could be damaged by orthodontic appliances nor whether the appliances would cause discomfort. Parents had significantly more negative perceptions of both types of orthodontic appliances than did the students. The Perceptions scores were not significantly influenced by whether the students attended a private or public sector dentist, the frequency of dental visits, any history of orthodontic treatment, nor by the parents' level of education and their occupations. A forewarning about experiences of orthodontic appliances would better prepare patients and assist operators in providing the community with a more comprehensive orthodontic service.

Physiological root resorption of primary molars.

Physiological root resorption of primary molars was assessed using bitewings and orthopantomograms. Thirty-six per cent of teeth examined demonstrated reduced root resorption of one or more roots. Excepting the lower first primary molar, the present study recorded a relatively high incidence of uneven root resorption during the exfoliative process, particularly evident for the upper second primary molar. Discrepancy in size between the premolar and its predecessor, as well as the position of the developing permanent tooth in relation to primary root structure influences the pattern of root resorption. Therefore, constant monitoring of teeth demonstrating uneven resorption is required to avoid the complications associated with over-retained teeth.