F. Accadbled

Induced-membrane femur reconstruction after resection of bone malignancies: Three cases of massive graft resorption in children

Bone reconstruction after surgical resection of bone malignancies in children remains a difficult challenge. Induced-membrane reconstruction as described by Masquelet et al. was originally reported in traumatic or septic bone defects and is now adapted to this field. We report here three cases of massive femoral graft resorption requiring surgical revision in two boys aged 3 and 6 years and a 9-year-old girl. Hypotheses include the long delay between the two stages, nature of the bone graft, high varus loads specific to this location, and lack of stability of the fixation. This technique has recently provided promising preliminary results when applied to the field of bone tumours. However, reconstruction of the femur seems to be specifically associated with a risk of graft resorption. Identification of the origin of this major complication is needed to amend the technique or its indications.

Arthroscopic treatment of discoid meniscus in children: Clinical and MRI results

INTRODUCTION Treatment of symptomatic discoid meniscus in children is saucerization performed under arthroscopy. The strategy to adopt for associated meniscus lesions is discussed, from partial meniscectomy to meniscal repair. The latter was applied in the series studied herein. The objective was to assess this surgical strategy. PATIENTS This was a retrospective study of 20 discoid menisci (18 patients) operated between 2004 and 2007. METHOD The patients first underwent arthroscopic saucerization and then, a procedure that depended on the residual meniscus: no additional procedure if there was no lesion, suturing or reinsertion in cases with a repairable lesion, and partial meniscectomy in cases of a non repairable lesion. All patients were assessed clinically and with postoperative MRI. RESULTS The mean follow-up was 37 months. Five discoid menisci presented no lesion and were treated with isolated saucerization. Fifteen discoid menisci presented a lesion. In four cases, saucerization removed this lesion. In eight cases, we performed meniscal repair after saucerization. In three cases, partial meniscectomy was necessary. The Lysholm score ranged from 67 to 88. Sixteen patients were satisfied or very satisfied in 16 cases. The mean Tegner score was 5.9. Postoperative MRI showed no signs of chondral degeneration. The mean measurements of the residual meniscus corresponded to the guidelines. Patients having undergone saucerization associated with meniscal repair had better results than those who had partial meniscectomy or meniscus repair alone (P=0.007, Fisher test). DISCUSSION No other study having evaluated discoid meniscus surgery with postoperative MRI has been reported and few studies have been published on saucerization associated with repair. This approach spares the meniscus, as confirmed by MRI, with the size of the residual meniscus within the guidelines. We obtained good clinical and anatomic results, with good healing of the meniscus and satisfactory measurements.

Osteoid osteoma of the elbow in children: a report of three cases and a review of the literature.

Although osteoid osteoma is a relatively common lesion, it is rarely found at the elbow. We report three cases of osteoid osteoma of the olecranon fossa in patients under the age of 15 years. Diagnosis was delayed because of nonspecific clinical and radiological features. The three patients suffered from synovitis due to flexion contracture while at the same time prosupination remained normal. Only one patient complained of specific nocturnal pain. All cases had a latency between the onset of symptoms and the appearance of radiological signs. Open surgical excision of the nidus resulted in relief of pain in all cases and motion recovery in two cases. Diagnostic difficulties and treatment options are discussed.

Arthrolyse antérieure de l'épaule sous arthroscopie dans les séquelles de paralysie obstétricale du plexus brachial. Résultats préliminaires

PURPOSE OF THE STUDY Retraction of the shoulder in internal rotation is observed in 25% of children with brachial plexus birth palsy (C5, C6 +/- C7). Early bone and joint deformities affecting the glenohumeral joint are the consequences. The stiff internal rotation requires surgical release which can involve the capsule and ligaments, muscles, or both. Internal release can be combined with muscle transfer to improve active external rotation. We report the results obtained with arthroscopic anterior capsular release combined with latissimus dorsi transfer. MATERIAL AND METHODS From 1999 through 2006, fourteen children with a stiff shoulder in internal rotation secondary to brachial plexus birth palsy were managed in our unit. All had recovered biceps function six months after surgery. The glenohumeral dysplasia was analyzed on the preoperative magnetic resonance imaging. Pre- and postoperative passive external rotation (RE) were measured with the arm along the body and at 90 degrees elbow flexion. Internal rotation was measured using the Mallet score (hand-back test). Combined active abduction antepulsion was measured when the child was playing. Mean age at surgery was three years six months. Arthroscopic internal release was performed for eight children. All had an associated latissimus dorsi transfer. RESULTS Among the 14 children managed in the unit, arthrolysis was not be performed in six, either because of the lack of an adequate electrode (two patients) or because the child presented posterior glenohumeral dislocation making it impossible to introduce the optic channel (four patients). Arthroscopic anterior release was performed for the eight other patients. These eight patients were reviewed at a mean three-year follow-up. Passive external rotation was improved, with a mean gain of 60 degrees with no recovery of passive internal rotation. The abduction antepulsion movement was also improved, mean gain 90 degrees . DISCUSSION A stiff shoulder in internal rotation can develop during the first two years of life. Several techniques have been proposed for internal release. The origin of the progressive limitation of passive external rotation remains a subject of debate. Is it due to retraction of the internal rotators, or to capsule-ligament retraction, or both? In 1992, Harryman et al. demonstrated the role of the capsule and the coracohumeral ligament in limiting external rotation. Consequently, we have opted for early release (less than two years of age) using an arthroscopic method limited to the capsule and ligaments. Our results for passive external rotation are comparable to those reported by others. However, this technique enables preserved mobility for internal rotation. CONCLUSION Arthroscopic anterior release limited to the capsule and the ligaments is an effective, minimally invasive technique. Leaving the internal rotator muscles intact preserves internal rotation of the shoulder and reduces the risk of anterior instability.

All inside transtibial arthroscopic posterior cruciate ligament reconstruction in skeletally immature: Surgical technique and a case report

UNLABELLED Posterior cruciate ligament (PCL) tears are rare in children and may cause posterior instability of the knee. We present an original reconstruction technique. An 11-year-old boy sustained a PCL rupture. Despite initial immobilization followed by physiotherapy, he could not resume his previous sporting activities at the pre-injury level and complained of anterior knee pain. We performed an arthroscopic PCL reconstruction using a single bundle four-strand hamstring autograft. The femoral tunnel was drilled through the epiphysis and the tibial tunnel went through the physis under both arthroscopic and fluoroscopic control. The graft was secured using absorbable interference screws. At 2 years follow-up, the patient was asymptomatic and resumed sports at the same level as before the injury. Clinical examination was normal. There was no sign of growth disturbance. PCL injury is extremely rare in children. This original technique seemed appropriate in a symptomatic patient. LEVEL OF EVIDENCE IV.

Prognosis value of early diffusion MRI in Legg Perthes Calvé disease

PURPOSE To evaluate diffusion MRI of the proximal femoral epiphysis and metaphysis as a prognosis factor in Legg Calvé Perthes (LCP) disease. METHODS Thirty-one children (mean age 5.5 years, range 2.5-10.5) with unilateral LCP were included in a prospective, consecutive series. Radiographs were analysed and classified as per Herring criteriae. Mean follow-up was 19 months (range 6-30). Forty-nine MRI scans were performed at either the condensation or fragmentation stage. Apparent Diffusion Coefficient (ADC) of both the femoral epiphysis and metaphysis were measured bilaterally and ADC ratio were calculated, then compared to the Herring group. RESULTS Sixteen hips were rated Herring A or B, 3 Herring B-C and 12 Herring C. ADC was increased in affected hips compared to unaffected sides, both at the femoral epiphysis (P<0.001) and metaphysis (P<0.0001). ADC ratio of the femoral metaphysis was positively correlated to Herring classification: if superior to 1.63, it was associated with a bad prognosis (Herring B-C or C) (P=0.0017, sensitivity=89%, specificity=58%). Interobserver reliability of ADC measurement was excellent. The 1.63 threshold could be determined as early as the condensation stage. CONCLUSIONS Diffusion presents several advantages including being non radiating and non invasive. It does not need contrast medium administration and it can be performed without anaesthesia. The origin of the increased ADC remains unknown. Basically, it reflects molecular changes (true diffusion) but it is also influenced by the vascular supply (pseudo-diffusion). ADC ratio could provide an early prognosis before Herring classification is applicable. LEVEL OF EVIDENCE Level III. Prospective uncontrolled study.

Isolated meniscal injuries in paediatric patients: Outcomes after arthroscopic repair

BACKGROUND The management of isolated meniscal tears in paediatric patients is poorly standardised, and few published data are available. Nevertheless, there is widespread agreement that meniscectomy, even when partial, produces poor outcomes including the premature development of osteoarthritis. HYPOTHESIS Arthroscopic repair of isolated meniscal tears in paediatric patients yields good outcomes and should be attempted routinely. MATERIALS AND METHODS We retrospectively assessed 19 arthroscopic repair procedures performed between 2006 and 2010 by a single surgeon in 17 patients with a mean age of 14 years. In every case, the knee was stable and the meniscus normal before the meniscal tear, which was the only injury. Mean follow-up was 22 months. In all 19 cases, the evaluation included a physical examination, pre-operative magnetic resonance imaging (MRI), and determination of the Tegner and Lysholm scores. Post-operative MRI was performed in 10 cases. RESULTS The outcome was good in 12/17 (70%) patients with significant improvements in the mean Tegner score, from 3.9 to 7.1, and mean Lysholm score, from 55.9 to 85.4, between the pre-operative and post-operative assessments. The clinical outcomes were not significantly associated with time to arthroscopic repair, gender, lesion site, or lesion type. Neither was any correlation demonstrated between clinical outcomes and meniscal healing as assessed by MRI. DISCUSSION The known poor outcomes after meniscectomy in paediatric patients, the results of our study, and previously published data support routine arthroscopic repair of isolated meniscal tears in this age group, regardless of the site and type of injury. In addition, in asymptomatic patients, clinical follow-up is sufficient and post-operative MRI unnecessary. LEVEL OF EVIDENCE Level IV. Retrospective study.

Substructuring and poroelastic modelling of the intervertebral disc

We proposed a substructure technique to predict the time-dependant response of biological tissue within the framework of a finite element resolution. Theoretical considerations in poroelasticity preceded the calculation of the sub-structured poroelastic matrix. The transient response was obtained using an exponential fitting method. We computed the creep response of an MRI 3D reconstructed L(5)-S(1) intervertebral disc of a scoliotic spine. The FE model was reduced from 10,000 degrees of freedom for the full 3D disc to only 40 degrees of freedom for the sub-structured model defined by 10 nodes attached to junction nodes located on both lower and upper surfaces of the disc. Comparisons of displacement fields were made between the full poroelastic FE model and the sub-structured model in three different loading conditions: compression, offset compression and torsion. Discrepancies in displacement were lower than 10% for the first time steps when time-dependant events were significant. The substructuring technique provided an exact solution in quasi-static behavior after pressure relaxation. Couplings between vertical and transversal displacements predicted by the reference FE model were well stored by the sub-structured model despite the drastic reduction of degrees of freedom. Finally, we demonstrated that substructuring was very efficient to reduce the size of numerical models while respecting the time-dependant behavior of the structure. This result highlighted the potential interest of substructure techniques in large-scale models of musculoskeletal structures.

Comportamiento de la primera cuña en la corrección quirúrgica del metatarso adducto

Objetivo El metatarso adducto (MTA) es una deformacion en adduccion del antepie. Nuestro objetivo es apoyar la hipotesis por la cual la principal anomalia se encuentra en el lado cuneiforme de la articulacion cuneo-metatarsiana, y que el crecimiento de la primera cuna es fundamental en la correccion tras la capsulotomia. Material y metodo Se trata de un estudio radiologico realizado con 23 ninos con MTA idiopatico o secundario a pie zambo, operados entre los anos 1982 y 2000, con liberacion de la articulacion cuneo-metatarsiana. Se realizaron radiografias de los 30 pies operados, y de 12 pies contralaterales utilizados como controles, con las siguientes mediciones: angulo cuneo-metatarsiano (FMCA), angulo de inclinacion distal de la primera cuna (DCAA), angulo entre esta superficie y la del primer metatarsiano (PENTE) y angulo proximal articular del primer metatarsiano (PMAA). Se compararon las medias de estos angulos tomadas en pre, post-operatorio inmediato y final del seguimiento, mediante los pertinentes tests estadisticos. Resultados Respecto al MTA idiopatico, el FMCA aumento de 150,4° en el preoperatorio a 170,2° al final, el DCAA paso de 62° a 81,1°, y el PMAA de 88,4° a 89,1°. Respecto al MTA secundario a pie zambo, el FMCA aumento de 155,3° a 169,7°, el DCAA paso de 61,9° a 79,7°, y el PMAA de 88,3° a 90°. En el lado sano los angulos apenas se modificaron. Conclusiones La oblicuidad de la articulacion cuneo-metatarsiana medial esta estrechamente relacionada con el metatarso adducto. La correccion post-quirurgica se hace tambien a expensas de este hueso, que tiende a rellenar el espacio creado por la capsulotomia.

Reconstruction osseuse des os longs après exérèse carcinologique par l’utilisation de greffons fibulaires vascularisés chez l’enfant et l’adolescent

PURPOSE OF THE STUDY The vascularized fibular graft is a widely used technique for the reconstruction of long bone defects after tumor resection. Complications are not uncommon despite the presence of a good vascular supply. We report our experience with long bone reconstructions in children and adolescents after resection of primary malignant bone tumors. MATERIAL AND METHODS This retrospective analysis included thirteen patients aged 4-17 years (mean age 12 years). Preoperatively, the pathological diagnosis was Ewing tumor (n=7), osteogenic sarcoma (n=5), neuroepithelioma (n=1). All patients except one were given chemotherapy preoperatively and postoperatively and four received adjuvant radiotherapy. Tumor resection created a gap (n=8) or involved resection-arthrodesis (n=5, three knees, one ankle, one elbow). All reconstructions used a vascularized fibular flap with a complementary corticocancellous autograft for seven. RESULTS Complete carcinological resection was achieved in all cases. Mean follow-up was 50 months (range 12-144 months). There were no cases of local recurrence. Three patients presented lung metastasis; two patients died. Eleven of the twelve patients who underwent tumor resection involving the lower limb were able to walk with full weight bearing at 13.9 months (range 841 months), half of them without any supportive device. The MSTS score was 21/30 (range 7-29). Both ends healed for eleven of thirteen grafts. Outcome was good in four cases at 7.7 months (range 6-11), fair in seven (with 1-5 complementary procedures) at 14.8 months (range 10-45) and poor in two (nonunion at last follow-up). Among the fibular grafts which healed, primary healing of the distal end was noted in all cases, but not for the proximal end. Significant transplant hypertrophy was noted in 62% of patients, measured at mean 77.1% (range 25-128%). Complications were: skin necrosis (n=2), nonunion (n=4, three aseptic and one septic), disassembly (n=3 with two transplant fractures), and spontaneous fracture which healed (n=5, all but one treated orthopedically). There were four donor site complications: retraction of the hallux flexor (n=3), regressive paresia of the common fibular nerve (n=1). DISCUSSION The rate of healing in this series was similar to earlier reports. Healing was always achieved for the distal focus but not for the proximal focus which receives its blood supply from a branch of the anterior tibial artery which is not harvested. The defective blood supply can thus hinder bone healing. It is necessary to spare the proximal quarter of the fibula or harvest a bipediculated graft. The rate of graft hypertrophy was also similar, as was the rate of complications. The MSTS score was lower due to the poor results obtained with resection-arthrodesis of the knee joint. Graft fractures and aseptic nonunion are the most common complications but septic complications are more serious and can threaten graft survival. Complications at the donor site are exceptional. CONCLUSION Long bone reconstruction using an autologous vascularized fibular graft is a reliable technique providing satisfactory functional results. Complications can be prevented by making solid fixation and using a corticocancellous graft creating a favorable osteoinducing environment. A massive allograft is another solution providing good immediate mechanical stability.Resume La technique des greffons fibulaires vascularises fait partie de l’arsenal therapeutique des reconstructions des pertes de substance osseuse apres exerese tumorale. Nous rapportons notre experience concernant cette technique chez l’enfant apres resection carcinologique de tumeurs osseuses primitives malignes. Il s’agit d’une serie retrospective de 13 patients d’âge moyen 12 ans (4-17) comportant : 7 tumeurs d’Ewing, 5 osteosarcomes, un neuroepitheliome. Tous les patients (sauf un) ont beneficie d’une chimiotherapie pre et postoperatoire et 4 d’une radiotherapie adjuvante. Nous avons realise une reconstruction par fibula vascularisee a pedicule fibulaire, associee 7 fois a une autogreffe cortico-spongieuse, apres 8 resections intercalaires et 5 resection-arthrodeses. L’exerese carcinologique a toujours ete complete. Au recul de 50 mois (12-144), il n’y avait aucune recidive locale. Trois patients ont presente des metastases pulmonaires ; deux etaient decedes. Onze patients sur les douze operes au membre inferieur marchaient en plein appui a 13,9 mois (8-41) dont la moitie sans aucun appareillage. Le score MSTS etait de 21/30 (7-29). Onze transplants sur treize etaient solides aux deux extremites : 4 bons resultats a 7,7 mois (6-11), 7 moyens (une a 5 interventions supplementaires) a 14,8 mois (10-45) et 2 mauvais (non consolides). Tous les foyers fibulaires distaux ont consolide en premiere intention, a la difference des foyers proximaux. L’hypertrophie du transplant etait significative dans 62 % des cas, en moyenne 77,1 % (25-158). Les complications denombrees ont ete : 2 necroses cutanees, 4 pseudarthroses (3 aseptiques et une septique), 3 demontages (2 fractures du transplant) et 5 fractures spontanees, toutes traitees orthopediquement (sauf une) et ayant consolide. Quatre complications ont ete observees au site donneur : 3 retractions du flechisseur de l’hallux, une paresie regressive du nerf fibulaire commun.