F. Bergerault

Physeal-sparing reconstruction of anterior cruciate ligament tears in children: RESULTS OF 57 CASES USING PATELLAR TENDON

This study evaluated the results of a physeal-sparing technique of intra-articular anterior cruciate ligament (ACL) reconstruction in skeletally immature patients, with particular reference to growth disturbance. Between 1992 and 2007, 57 children with a mean age of 12.2 years (6.8 to 14.5) underwent ACL reconstruction using the same technique. At a mean of 5.5 years (2 to 14) after surgery, 56 patients underwent clinical and radiological evaluation. At that time, 49 patients (87.5%) had reached bony maturity and 53 (95%) achieved A or B according to the IKDC 2000 classification. Four patients had stopped participation in sports because of knee symptoms, and three patients (5.4%) had a subsequent recurrent ACL injury. There was no clinical or radiological evidence of growth disturbance after a mean growth in stature of 20.0 cm (3 to 38). This study demonstrates that ACL reconstruction sparing the physes in children is a safe technique protecting against meniscal tears and giving better results than reconstruction in adults, without causing significant growth disturbance.

The progression of lumbar curves in adolescent Lenke 1 scoliosis and the distal adding-on phenomenon.

INTRODUCTION The postoperative deterioration of the curve below spinal fusion instrumentation resulting in a distal adding-on (AO) phenomenon in idiopathic adolescent scoliosis (IAS) frequently requires surgical revision with disappointing secondary clinical results. HYPOTHESIS Analysis of AP (coronal) range of motion (cROM) and lateral (sagittal) range of motion (sROM) on dynamic (side-bending, flexion, extension) X-rays to determine the choice of the lowest instrumented vertebra (LIV) can help reduce distal adding-on. The goal of this study was to study the postoperative progression of the lumbar curve in Lenke 1 scoliosis operated on with a LIV based on dynamic X-ray results. MATERIALS AND METHODS Right-sided Lenke 1 IAS that was treated surgically by posterior arthrodesis alone with a follow-up of at least 2 years was included in the study. The following radiographic parameters were evaluated: the Cobb angles of the curves, reducibility of the curves, the apex of the scoliosis, the central sacral vertical line, the stable vertebra (SV), the neutral vertebra (NV), the distances between the CSVL and the centroids of the LIV and of the first vertebra below instrumentation, as well as the tilt of the superior endplates. sROM and cROM were determined on dynamic X-rays. RESULTS Fifty IAS were evaluated/185 files. Only three cases fulfilled the criteria for AO including two that were secondary to peri- or postoperative complications. The lumbar curve presented with a loss of correction of 0.9° at one year and 1.14° at the final follow-up. None of the parameters studied were correlated to the deterioration of the lumbar curve. DISCUSSION The choice of the LIV has been shown to influence the deterioration of the lumbar curve and the development of AO. The choice of the LIV based on an analysis of AP (coronal) and lateral (sagittal) range of motion seems to prevent the development of AO. LEVEL OF EVIDENCE 4, retrospective study.

The concordance of MRI and arthroscopy in traumatic meniscal lesions in children

INTRODUCTION Traumatic meniscal lesions in children must be diagnosed quickly and efficiently as a priority in order to conserve the meniscus and safeguard the future of the knee. They are often isolated and difficult to identify clinically. In the diagnostic work up stage, an excessive resort to diagnostic arthroscopy has given way to increasing use of MRI by radiologists without pediatric specialization. The present study examined the agreement between MRI aspect and arthroscopic exploration in traumatic meniscal lesions in children. PATIENTS AND METHODS Sixty-nine knees in children aged 9 to 16 years having undergone MRI followed by arthroscopy for knee trauma between 1995 and 2008 were included in a retrospective design. Discoid meniscus was excluded. Files were reviewed by a single clinician and MRI scans by a radiologist specialized in pediatric pathology. Cases of epiphyseal fusion were excluded. All files were analyzable. Agreement with arthroscopic findings as reference was assessed for presence, location and type of meniscal lesion. RESULTS Overall agreement with arthroscopy was respectively 78% and 82% on first and second MRI readings: 77% and 80% for the medial, and 78% and 84% for the lateral meniscus. On the first reading, there were 13 false positives for the medial and 5 for the lateral meniscus, versus 9 and 0 respectively on second reading. Overall sensitivity was 70% on first reading and 64% on second, and overall specificity 81% and 90%, respectively. DISCUSSION The present results, in line with the literature, may appear encouraging, but hide considerable disparity between analysis of the medial and of the lateral meniscus: MRI overestimated medial and underestimated lateral meniscus lesions. CONCLUSION MRI serves only as a support and does not provide sure diagnosis of meniscus lesion. Interpretation should take account of the clinical examination and the pediatric orthopedic specialists experience.

Roentgenographic measurement of angle between shaft and distal epiphyseal growth plate of radius.

To assess the accuracy of the use of the growth plate to shaft angle (GP-S) in the fractured distal radius, two prospective studies were performed. The first intraobserver study was made by three different observers who measured the GP-S angles of anteroposterior and lateral views of 62 wrist radiographs on two different occasions. The results showed a 95% concordance for a 5° tolerance on anteroposterior views and 7° on lateral views. The second, an interobserver study with six different observers, showed the same results. The results favored the use of the distal radius GP-S angle. It is an easy and accurate measurement that can be useful for the assessment of distal forearm deformities in children.

Lumbosacral arthrodesis for neuromuscular scoliosis using a simplified Jackson technique

UNLABELLED Treating patients with severe neuromuscular scoliosis by long spinal fusion improves their quality of life and provides significant comfort for the patient and caregivers. But lumbosacral (L5-S1) fusion is challenging in these patients because of the significant deformities that result in poor bone anchoring quality and a risk of impingement between the skin and implants. In 1993, Jackson described a L5-S1 fusion technique using S1 pedicle screws and intrasacral rods (implanted under X-ray guidance) that are linked to the construct above with connectors. The goal of this study was to evaluate the clinical and radiological results and the postoperative complications of a simplified version of this technique, which does not require connectors or X-ray guidance. MATERIALS AND METHODS Thirty-three patients were evaluated with a minimum follow-up of 4years (average 82months). Frontal balance, sagittal balance, Cobb angle, sacral slope, lumbar lordosis and lateral pelvic tilt in the frontal plane were assessed on preoperative, postoperative and follow-up X-rays. Intraoperative and postoperative complications were recorded. RESULTS Complete fusion was obtained in 32 patients. The average Cobb angle was 62° initially and was reduced to 20° after surgery and 24° at the final follow-up. The average lateral pelvic tilt was 10.3° (0 to 26°) initially; it was surgically corrected to an average of 7.5° (0 to 24°); the average secondary loss of correction was 1.2° (0 to 9°). The sacral slope was corrected to an average of 11.2°; an average of 0.2° had been lost at the last follow-up (0 to 18°). Although the average for lumbar lordosis was unchanged, the standard deviation went from 29° to 16° after the corrective surgery and 17° at the last follow-up, with large cluster of measurements around the average value of 40°. The deformity correction was comparable to the results with other techniques (Galveston, sacroiliac screws); the complication rate was similar but the non-union rate was lower. This simplified Jackson technique appears to be an effective, simple method for L5-S1 fusion to correct neuromuscular scoliosis as it provides stable results over time. LEVEL OF EVIDENCE Level IV, retrospective study.

Roturas del ligamento cruzado anterior en la edad pediátrica

La frecuencia y la gravedad de las lesiones del ligamento cruzado anterior en la edad pediatrica se han minimizado durante mucho tiempo. Debido a la evolucion desfavorable de muchas lesiones tratadas de forma conservadora, el tratamiento quirurgico se ha convertido en una necesidad. Se debe buscar previamente una lesion meniscal y tratarla evitando por todos los medios posibles una meniscectomia, incluso parcial. Una ligamentoplastia convencional como la que se realiza en los adultos no puede plantearse en los ninos, debido a los riesgos de trastornos secundarios del crecimiento. Antes de adoptar cualquier medida terapeutica, cuando se establece el diagnostico de rotura del ligamento cruzado anterior, se debe determinar el potencial de crecimiento residual. El procedimiento quirurgico realizado debe respetar los cartilagos de crecimiento del extremo superior de la tibia e inferior del femur en lo que respecta a la eleccion, el trayecto y la fijacion del trasplante. Si la tecnica se realiza de forma rigurosa, el riesgo de repercusion sobre el crecimiento es menor, porque la mayoria de los trastornos descritos en la literatura son secundarios a defectos tecnicos. Por tanto, se deben utilizar injertos tendinosos evitando la extraccion de pastillas oseas. Si se realizan tuneles transfisarios, deben ser de pequeno diametro y con un trayecto lo mas vertical y central posible. El material de fijacion debe quedar a distancia de las fisis, sin cruzarlas. No debe haber una pastilla osea ni un tornillo de interferencia a traves de los cartilagos de crecimiento en los tuneles. Se han desarrollado muchas tecnicas quirurgicas adecuadas. Las plastias transfisarias de tipo adulto, que suelen aparecer en la literatura anglosajona y que se recomiendan en los adolescentes, parecen causar mas trastornos del crecimiento. Las plastias especificas de la edad pediatrica realizadas con el ligamento rotuliano (ligamentoplastia de Clocheville), la fascia lata (tecnica de Jaeger) y el tendon cuadricipital (tecnica de Chotel) se describen de forma mas detallada en este articulo.

Rotture del legamento crociato anteriore nel bambino

Riassunto La frequenza e la gravita delle lesioni del legamento crociato anteriore nel bambino sono state per lungo tempo minimizzate. Di fronte all’esito sfavorevole delle lesioni trattate in modo conservativo, il trattamento chirurgico e divenuto una necessita. Una lesione meniscale deve prima di tutto essere ricercata e trattata evitando con tutti i mezzi una meniscectomia anche parziale. Una plastica legamentosa convenzionale come quella realizzata nell’adulto non e consigliabile nel bambino a causa dei rischi di alterazione della crescita secondari. Prima di qualsiasi presa in carico, quando si pone la diagnosi di rottura del legamento crociato anteriore, deve essere determinato il potenziale di crescita residua. La procedura chirurgica realizzata deve rispettare le cartilagini di accrescimento dell’estremita superiore della tibia e inferiore del femore, per cio che riguarda scelta, tragitto e fissazione del trapianto. Se la tecnica e condotta in modo rigoroso, il rischio di risentimento sulla crescita e minimo in quanto la maggior parte dei problemi descritti in letteratura e secondaria a errori tecnici. Occorre utilizzare innesti tendinei evitando il prelievo di bratte ossee. Se si realizzano tunnel transfisari, essi devono essere di piccolo diametro e i piu verticali e centrali possibili. Il materiale di fissazione deve essere posto a distanza dalle cartilagini di coniugazione senza attraversarle. Non vi devono essere bratte ossee o viti a interferenza attraverso le cartilagini di accrescimento nei tunnel. Sono state sviluppate diverse tecniche chirurgiche adatte. Le plastiche transfisarie di tipo adulto, frequenti nella letteratura anglosassone, raccomandate nell’adolescente, sembrano piu responsabili di problemi di crescita. Le plastiche specifiche per il bambino eseguite con il legamento rotuleo (plastica di Clocheville), fascia lata (tecnica di Jaeger) e il tendine quadricipitale (tecnica di Chotel) sono descritte in modo piu dettagliato in questo capitolo.