Alain Dimeglio

Orthopaedic treatment and passive motion machine: consequences for the surgical treatment of clubfoot.

The efficacy of orthopaedic treatment and its influence on clubfoot surgery has never been truly demonstrated. In the unsorted mass of clubfeet treated, it is difficult to determine exactly how effective orthopaedic treatment is for severely affected feet. If properly performed, perfectly synchronized, and supported by a Kinetec machine, such treatment can noticeably reduce the rate of operation and, when operation is still required, reduce its extent. In grade II soft > stiff feet with scores of 5-10, Kinetec-supported orthopaedic treatment is extremely effective. Operation is required in 32% of cases only, and posterior surgery is often sufficient. Lateral release, in this category, is never required. In grade III stiff > soft feet, with scores of 10-15, the efficacy of orthopaedic treatment associated with the Kinetec machine is far from negligible and operation most often includes posterior and medial release (PMR), variably associated with plantar release. Lateral release is exceptional (15%), and operation is necessary in 75% of cases. In grade IV stiff = stiff feet, with scores of 15-20, orthopaedic treatment with the Kinetec machine has a true, though limited, effect. In this category, operation is necessary in 90% of cases. Lateral release is performed in 50%. In the postoperative period, orthopaedic treatment combined with use of the Kinetic machine must be continued. Orthopaedic treatment coordinated with use of the machine has considerably shortened the duration of plaster cast immobilization; 2 months when operation included posterolateral-medial (PLMR) release or PMR, and only 1 month when operation was posterior release (PR). The machine has noticeably changed the results and has indisputably influenced operation on the whole.

Neurovascular complications and severe displacement in supracondylar humerus fractures in children: defensive or offensive strategy?

Out of 210 children suffering from severely displaced supracondylar fractures, 76 (36%) presented with immediate neurovascular complications: 47 (22%) were neurological, 16 (8%) vascular and 13 (6%) both. Injury to two nerves simultaneously was observed in six patients. The median nerve was affected in 28 cases, the ulnar nerve in 25 and the radial nerve in 13. Posterolateral displacement was associated with 86% of damage to the median nerve and 56% of damage to the ulnar nerve. Posteromedial displacement was associated with all incidents of injury to the radial nerve with one exception. Each patient made full neurological recovery, spontaneously and following primary or secondary neurolysis performed on nerve injuries in continuity. Two situations of primary abolition of the radial pulse were encountered, one involving a pink hand in 12.5% of cases and the other involving a white hand in 1.5% of cases. There was posterolateral displacement in three out of four patients. Postoperative vascularization was revealed by immediate return of the radial pulse in 26 patients and delayed return in three others. Urgent anatomical reduction of the fracture and its early fixation are crucial. A conservative therapeutic approach is customary in the majority of neurovascular complications. Prognosis is generally excellent. Ischaemia of the limb and total ruptures of the nerve are very rare.

The growing spine: how spinal deformities influence normal spine and thoracic cage growth

PurposeThis article aims to provide an overview of how spinal deformities can alter normal spine and thoracic cage growth.MethodsSome of the data presented in this article are gathered from studies performed in 1980 and 1990, and their applicability to populations of different ethnicity, geography or developmental stage has not yet been elucidated. In the present article, older concepts have been integrated with newer scientific data available to give the reader the basis for a better understanding of both normal and abnormal spine and thoracic cage growth.ResultsA thorough analysis of different parameters, such as weight, standing and sitting height, body mass index, thoracic perimeter, arm span, T1–S1 spinal segment length, and respiratory function, help the surgeon to choose the best treatment modality. Respiratory problems can develop after a precocious vertebral arthrodesis or as a consequence of pre-existing severe vertebral deformities and can vary in patterns and timing, according to the existing degree of deformity. The varying extent of an experimental arthrodesis also affects differently both growth and thoracopulmonary function.ConclusionsGrowth is a succession of acceleration and deceleration phases and a perfect knowledge of normal growth parameters is mandatory to understand the pathologic modifications induced on a growing spine by an early onset spinal deformity. The challenges associated with the growing spine for the surgeon include preservation of the thoracic spine, thoracic cage, and lung growth without reducing spinal motion.

Growth and adolescent idiopathic scoliosis: when and how much?

Growth in childhood and in puberty has a major influence on the evolution of spinal curvature. The yearly rate of increase in standing height and sitting height, bone age, and Tanner signs are essential parameters. Additionally, biometric measurements must be repeated every six months. Puberty is a turning point. The pubertal diagram is characterized by two phases: the first two years are a phase of acceleration, and the last three years is a phase of decelaration. Thoracic growth is the fourth dimension of the spine. Bone age is an essential parameter. Risser 0 covers two third of the pubertal growth. On the acceleration phase, olecranon evaluation is more precise than the hand. On the deceleration phase, the Risser sign must be completed by the hand maturation. A 30 degree curve at the very beginning of puberty has 100% risk of surgery. Any spinal, if progression is greater than 10 degree per year on the first two years of puberty the surgical risk is 100%.

Skeletal age assessment from the olecranon for idiopathic scoliosis at Risser grade 0.

BACKGROUND The main progression of idiopathic scoliosis occurs during peak height growth velocity, which is between the ages of eleven and thirteen years in girls and thirteen and fifteen years in boys and corresponds to the accelerating phase of pubertal growth. The Risser sign remains at grade 0 during this stage of growth. Triradiate cartilage closure occurs at approximately twelve years of age in girls and fourteen years in boys, which is in the middle of this phase. In addition to regular height measurements, a more detailed evaluation of skeletal maturity would be desirable prior to the identification of Risser grade 1. From the method of Sauvegrain et al., Diméglio derived a simplified method based on the radiographic appearance of the olecranon, which allows skeletal age to be assessed in six-month intervals. The purpose of this study was to determine the accuracy and the value of this simple method for the follow-up of patients with scoliosis. METHODS Five radiographic images demonstrate the typical characteristics of the olecranon during pubertal growth: two ossification nuclei, a half-moon image, a rectangular shape, the beginning of fusion, and complete fusion. This classification method was evaluated by three experienced and independent observers from lateral radiographs of the elbow in 100 boys and 100 girls with idiopathic scoliosis during the time of peak height velocity. Skeletal ages were correlated with the integral Sauvegrain method. The degree of interobserver concordance was determined, and skeletal age was compared with chronological age and the time of triradiate cartilage closure. RESULTS For the three observers, the average concordance between the Sauvegrain and olecranon methods was excellent (r = 0.977 for boys and r = 0.938 for girls). The interobserver agreement was also excellent (r = 0.987 for the olecranon method and r = 0.958 for the Sauvegrain method for boys, and r = 0.992 and r = 0.985, respectively, for girls). Skeletal and chronological age were considered to correspond to each other within a six-month range for 49% of the boys and 51% of the girls, while 25% of the boys and 26% of the girls had an advanced skeletal age and 26% of boys and 23% of girls had a delayed skeletal age. Triradiate cartilage closure occurred at the same time as the appearance of the rectangular shape of the olecranon in 65% of the boys and 61% of the girls, corresponding to skeletal ages of fourteen and twelve years, respectively. In 91% of the boys and 88% of the girls, the triradiate cartilage fused within six months before to six months after the appearance of the rectangular shape of the olecranon, which occurred between the half-moon image and the beginning of fusion of the olecranon. CONCLUSIONS The method of assessing skeletal age from the olecranon allows skeletal maturity to be evaluated in regular six-month intervals during the phase of peak height velocity. This method is simple, precise, and reliable. It complements the Risser grade-0 and the triradiate cartilage evaluation.

Congenital pseudarthrosis of the forearm—Two cases treated by free vascularized fibular graft

Congenital pseudarthrosis of the forearm is rare, and only two cases are reported in association with Von Recklinghausens disease. One case had pseudarthroses of both forearm bones treated successfully by free vascularized fibular grafts from both legs, and the other had radial bowing ulnar hypoplasia treated successfully with one free vascularized fibular graft between the proximal ulna and distal radius.

Normal and abnormal spine and thoracic cage development

Development of the spine and thoracic cage consists of a complex series of events involving multiple metabolic processes, genes and signaling pathways. During growth, complex phenomena occur in rapid succession. This succession of events, this establishment of elements, is programmed according to a hierarchy. These events are well synchronized to maintain harmonious limb, spine and thoracic cage relationships, as growth in the various body segments does not occur simultaneously at the same magnitude or rate. In most severe cases of untreated progressive early-onset spinal deformities, respiratory insufficiency and pulmonary and cardiac hypertension (cor pulmonale), which characterize thoracic insufficiency syndrome (TIS), can develop, sometimes leading to death. TIS is the inability of the thorax to ensure normal breathing. This clinical condition can be linked to costo-vertebral malformations (e.g., fused ribs, hemivertebrae, congenital bars), neuromuscular diseases (e.g., expiratory congenital hypotonia), Jeune or Jarcho-Levin syndromes or to 50% to 75% fusion of the thoracic spine before seven years of age. Complex spinal deformities alter normal growth plate development, and vertebral bodies become progressively distorted, perpetuating the disorder. Therefore, many scoliotic deformities can become growth plate disorders over time. This review aims to provide a comprehensive review of how spinal deformities can affect normal spine and thoracic cage growth. Previous conceptualizations are integrated with more recent scientific data to provide a better understanding of both normal and abnormal spine and thoracic cage growth.

Normal Growth of the Spine and Thorax

The growing spine is the product of more than 130 physes or growth plates. Growth holds the basics; it is a ratio between remaining and elapsed growth, and any surgical strategy should be adjusted according to remaining growth. As the spinal deformity progresses, not only spinal growth is affected but also the size and shape of the thorax are modified. There is a normal interaction between the organic components of the spine, the thoracic cage, and the lungs. Both early-onset spinal deformities and an early spinal arthrodesis alter spinal growth and affect thorax development by changing its shape and reducing its normal mobility. As a “domino effect,” the distortion of the thorax will eventually interfere with lung development and cardiac function, leading those children to develop thoracic insufficiency syndrome and cor pulmonale, which can be lethal in the most severe cases.

Influence of idiopathic scoliosis on three-dimensional thoracic growth.

Study Design. Prospective clinical study of three-dimensional thoracic growth in children with idiopathic scoliosis and a reference group. Objective. To measure thoracic dimensions and volume in relation to growth and to verify the influence of scoliosis. Summary of Background Data. Scoliosis represents a three-dimensional spinal deformity leading to thoracic deformity. Vertical expandable prosthetic titanium rib distraction primarily treats this deformity, but little is known about thoracic growth in scoliosis. Methods. One hundred and thirty children with scoliosis (20 boys, 110 girls; 4–16 years; curves 15°–45°; rib hump 5–25 mm) were compared with 126 children without spinal deformity (61 boys, 65 girls). The ORTEN system was used for optical trunk surface data acquisition. Thoracic volume, perimeter, anterior-posterior and transversal diameters, T1–T12 and sternal lengths were calculated and related to age, weight, standing and sitting height. Results. There was no significant difference in thoracic volume between the 2 groups (P > 0.05). The correlation between thoracic volume (3–16 dm3) and growth parameters was greater (R2 > 0.70) than with age. At 4 years, thoracic volume represents 33%, and at 10 years, it represents 55% of its volume at 16 years. It triples between 4 and 16 years and doubles during puberty. These relationships were constant in all groups. During growth, the transversal diameter corresponds to 30%, the anterior-posterior diameter represents 20% and the thoracic perimeter 100% of sitting height. Conclusion. The thoracic deformity in scoliosis is measurable with ORTEN, but scoliosis ≤45° with a rib hump ≤25 mm does not significantly influence thoracic volume. Thoracic parameters should be related to sitting height rather than age. Established relationships give a reliable indication of thoracic proportions, which are useful for understanding global spinal and thoracic deformity and for optimizing braces or surgical strategies. Further investigations are required for curves >45°, leading to major thoracic asymmetry.

The French functional physical therapy method for the treatment of congenital clubfoot.

The French method, also called the functional physical therapy method, is a combination of physiotherapy, splinting and surgery à la carte. The French functional physical therapy method consists of daily manipulations of the newborn’s clubfoot by a specialized physical therapist, stimulation of the muscles around the foot and temporary immobilization of the foot with elastic and nonelastic adhesive taping. Physiotherapy is optimized by early triceps surae lengthening. Sequences of plaster can also be used. If conservative treatment is no longer effective, surgery should be considered. Mini-invasive surgery is a complementary procedure to nonoperative treatment (surgery ‘à la carte’). The French method reduces but does not eliminate the need for mini-invasive surgical procedures. Equinus is the most difficult deformity to treat; posterior release is sometimes necessary in a severe foot. Very severe feet (stiff–stiff; score, 16–20) are still a challenge. However, regular manipulations and splinting improve foot morphology and stiffness, and, ultimately, make surgery easier and less extensive. From the French method to the Ponseti method, the Hybrid method or the ‘the third way’, combining the advantages of both methods, is the future. The primary reason for relapses is the inability of families to maintain the correction initially achieved. The aim of this work is to provide an overview of the French functional physical therapy method and to help understand how it has evolved over time.