F. Launay

Limb lengthening and deformity correction in children using hexapodal external fixation: preliminary results for 36 cases.

Limb deformities in children can be corrected using different techniques, notably external fixation following the Ilizarov principles. However, correction can be difficult in cases of multiple deformities. In 1994, Charles Taylor developed a new computer-assisted hexapodal external fixator system to treat these pathologies, the Taylor Spatial Frame. The objective of this study was to evaluate the results obtained with this technique in treating lower-limb deformities in children. Thirty-six patients were included in this prospective study, with a mean age of 11.1 years. The etiologies were distributed into six groups: congenital pathologies in 17 cases, fractures in five cases, post-traumatic pathologies in two cases, postinfectious sequelae in three cases, achondroplasia in three cases, and other causes in the last six cases. A total of 67 deformities in the three spatial planes were found in the entire group of patients. The procedure consisted of lengthening, correcting the axis, or both simultaneously. All the patients were managed with the same protocol: placement of an external fixator, AP and lateral X-rays, and planning of the correction using dedicated software. In this group of 36 patients, the fixator was worn for a mean 183 days; when lengthening was performed, a mean 4.3cm was gained with a healing index of 38.2 days/cm. Of the 67 initial deformities, 91% were corrected. The most frequently encountered complications were a superficial infection in 22.2% of the cases; one deep infection was also noted as well as three bone regenerate fractures. Use of this computer-assisted fixation system seems effective in treating complex deformities of the limbs in children, and allows treating several deformities simultaneously.

Child pectus excavatum: correction by minimally invasive surgery.

INTRODUCTION Pectus excavatum (PE) is a congenital deformity essentially responsible for an unattractive aspect, much more rarely for compression problems. The classical treatments consist either in filling the excavation or in open thoracic reconstruction (the Ravitch technique). Alternatively, the treatment described by Nuss raises the sternum with a retrosternal metallic bar placed under thoracoscopic guidance. We present the preliminary results of a series of 25 children operated on using this technique. HYPOTHESIS The minimally invasive procedure described by Nuss is a valid surgical strategy to treat PE. MATERIALS AND METHODS Twenty-five patients were operated on between February 2004 and April 2007 by the same surgeon. Nineteen of these patients presented a purely cosmetic indication. The six other patients were considered to have a more severe form of PE, with cardiorespiratory repercussions. In this group, there were two cases of Marfan syndrome and two patients presenting a history of previous cardiothoracic surgery. The technique has always consisted in placing a retrosternal bar through two lateral incisions. The surgery was always performed with right lung exclusion and was guided by thoracoscopy in 21 cases. In four particularly severe cases, a subxiphoid approach was required, making endoscopic guidance unnecessary. The severity of the lesion was evaluated by the Haller Index. All the patients had regular clinical follow-up (at three weeks, three months, and then every six months); assessment of pain, satisfaction with the cosmetic results, and perceived improvement in respiratory function were the criteria used for this follow-up. RESULTS The cosmetic result was judged to be positive by 24 patients. One patient was dissatisfied (because of the asymmetrical shape resulting from the use of a single implant). Five patients presented minor complications with no repercussions on the cosmetic or functional result. One case of secondary bar displacement required revision on day 15. Following this revision evolution was uncomplicated (discharge on day 7 and activities resumed at three weeks). Finally, the hardware was removed at a delay after implantation ranging from one to two years. As of today, 13 patients have had their hardware removed with no complications or loss of the initial result. DISCUSSION The original indication of the Nuss technique remains symmetrical PE in seven to 14-year-old children. The insubstantial scarring makes the technique valuable in the purely cosmetic forms of the condition. Based on this series, our technique has evolved toward certain adjustments depending on the severity and the etiology of the lesion. The most reported complication in the literature is secondary displacement of the bars. This problem is easily controlled by attaching the bar to a rib. Over the years, we have modified the implant design so as to improve its tolerance and stability. In asymmetrical forms of PE, implanting two bars has provided better efficacy. When a major form is present or when there is a history of cardiorespiratory problems, we recommend a short subxiphoid incision to release the pleural and pericardial adherences, precluding the need for thoracoscopic guidance. With these simple adjustments, this technique gains in reliability for cosmetic indications and its use can be extended to specific forms such as collagenosis or postoperative deformities. LEVEL OF EVIDENCE Level IV. Therapeutic Study.

Fatal lung metastasis secondary to index finger giant cell tumor in an 8-year-old child

We report the case of a 7-year-old girl presenting with giant cell tumor (GCT) of the index finger, complicated by lung metastases. Index disarticulation, pulmonary metastasectomy and chemotherapy failed to produce a cure, and the child died at the age of 8 years after 1 years evolution. The pulmonary metastases were discovered following hypoxia during initial biopsy. A review of the literature shows this observation to be original, in terms of the patients age and of the location, onset and fatal outcome of metastasis. The hypoxic episode complicating biopsy raises the issue of early screening for lung metastases in GCT. Pulmonary dissemination of GCT is of severe prognosis.

Surgical treatment of the symptomatic os trigonum in children

Symptomatic os trigonum is a rare condition, well described in adults, that causes chronic ankle pain. To date there are no reported cases of successfully managed symptomatic os trigonum in the children population. We retrospectively reviewed four paediatric patients (11-17 years of age) successfully operated for a symptomatic os trigonum using an open excision through a posteromedial approach. One case was bilateral. Postoperative pain relief was obtained in all cases. All of the patients were able to return to unrestricted physical activities after three months. The average follow-up was 12 months. Symptomatic os trigonum may be held responsible for chronic ankle pain in children and adolescents as well as in adults. The surgical treatment is effective in children.

Proximal migration of fibular malleolus during tibial lengthening despite syndesmotic screw fixation: a series of 22 cases.

INTRODUCTION During tibial lengthening procedures, it is recommended to prevent fibular malleolus proximal migration using a distal tibiofibular syndesmotic screw, which is removed at 6 months. We have observed proximal migrations of the fibular malleolus despite placement of this syndesmotic screw. OBJECTIVE The objective of this study was to demonstrate this migration and to study the influence of two factors that may favor its occurrence: positioning of the syndesmotic screw and union of the fibula at the time of removal. HYPOTHESIS An unhealed fibula at the time the distal tibiofibular syndesmotic screw is removed and its tricortical position promote the proximal migration of the fibular malleolus. MATERIAL AND METHODS This was a retrospective, single-center, analytical study that included 22 lengthening procedures in 18 patients from 5 to 17 years of age who had undergone tibial lengthening and presented a preoperative continuous fibula. The position of the fibular malleolus, union of the fibula, and the tri- or quadricortical position of the screw were assessed based on four successive x-rays. RESULTS Tricortical positioning of the syndesmotic screw was significantly associated with proximal migration of the fibular malleolus during lengthening (P=0.0248<0.05). However, there was no significant relation between an unhealed fibula and proximal migration of the fibular malleolus when the screw was removed (P=0.164>0.05). DISCUSSION Proximal migration of the fibular malleolus during lengthening is promoted by placing a non-quadricortical syndesmotic screw. Quadricortical positioning of the screw should be recommended. Migration of the fibular malleolus after ablation of the syndesmotic screw seems to be related to absence of fibular union but this series was too small to demonstrate this clearly. LEVEL OF EVIDENCE Level IV: Retrospective study.

Symptomatic os trigonum in children

BACKGROUND Symptomatic os trigonum is a rare condition well described in adults responsible for chronic ankle pain. To date there is no published case of successfully managed symptomatic os trigonum in children. METHODS We retrospectively reviewed 4 paediatric patients (11-17) successfully operated on for a symptomatic os trigonum through a postero medial approach. One case was bilateral. RESULTS Pain relief was postoperatively obtained in all cases. All of the patients were able to return to physical activities after 3 months. The mean follow up was 12 months. CONCLUSION Symptomatic os trigonum may be responsible for chronic ankle pain in children and adolescents as well as in adults. The surgical treatment is effective in children.

Embolie graisseuse au cours des allongements de membres par clou centromédullaire : à propos de trois cas

Several methods are available for progressive limb lengthening, including centromedullary nailing, external fixation, or a combination. Each technique has its own advantages and drawbacks. In trauma victims, use of centromedullary nailing is associated with potentially fatal fat embolism. This fatal outcome might also occur during limb lengthening, particularly in bilateral procedures. To our knowledge, fat embolism has not been reported with the use of centromedullary nail for limb lengthening. This was a multicentric study of three cases of fat embolism, including one fatal outcome. In all, 36 centromedullary lengthening nails were inserted in the three centers before these acute episodes. The first two cases occurred during single-phase bilateral procedures, the third during unilateral lengthening. Fat embolism could result from several factors, as reported in the literature. While the bilateral nature of the procedure has been incriminated, the observation of an embolism during a unilateral procedure suggests other factors may be involved. Considerable increase in endomedullary pressure during reaming and insertion of the nail has been demonstrated. At the same time, there is the question as to whether the reduction of the diminution of medullary pressure by corticotomy would be an efficient way of reducing the risk of fat embolism. Based on the analysis of our three cases, we suggest that the best way to avoid fat embolism might be to drill several holes within the area of the osteotomy before reaming, in order to reduce endomedullary pressure. This can be achieved via a short skin incision, sparing the periosteum before low energy osteotomy. Since applying this protocol, the three centers have implanted 17 lengthening nails, without a single case of fat embolism.

Évolution dans le traitement mini-invasif du pectus excavatum chez l'enfant : Résultats préliminaires à propos de 33 cas

L’indication princeps de la technique de Nuss reste le PE symétrique chez l’enfant de 7 à 14 ans. La faible rançon cicatricielle rend la technique intéressante dans les formes cosmétiques pures [4]. À partir de cette série, notre technique a évolué vers certains aménagements en fonction de la gravité et l’étiologie de la lésion. La complication principale retrouvée dans la littérature est la mobilisation secondaire des plaques [3,5]. Ce problème est facilement contrôlé par la fi xation de la plaque à une côte. Au cours de notre expérience, nous avons modifi é le dessin de l’implant afi n d’améliorer sa tolérance et sa stabilité. Dans les formes asymétriques, la mise en place de deux plaques permet une meilleure effi cacité (Fig. 3). Lorsque se présente une forme majeure ou lorsque existent des antécédents cardio-respiratoires, nous recommandons une courte incision sous xiphoïdienne afi n de libérer les adhérences pleurales et péricardiques. Dans cette alternative un contrôle thoracoscopique n’est pas nécessaire. Moyennant ces aménagements simples cette technique gagne en fi abilité dans les indications cosmétiques et peut s’étendre aux formes particulières que constituent les collagénoses et les déformations post opératoires. Le pectus excavatum (PE) est une malformation congénitale responsable essentiellement d’un aspect inesthétique et beaucoup plus rarement de problèmes compressifs. Les traitements classiques consistent en un comblement de l’excavation ou à la reconstruction thoracique à ciel ouvert comme dans les techniques de Ravitch [1] et Bedouelle [2]. Le traitement décrit par Nuss et al. [3] et Metzelder et al [4] consiste au relèvement du sternum par une plaque métallique rétro sternale mise en place sous contrôle thoracoscopique. Nous présentons les premiers résultats et les modifi cations apportées à propos d’une série de 33 enfants opérés selon ce principe.

SOFOP-05 – Chirurgie orthopédique – Spondylolisthésis de haut grade : traitement par vis sacro-lombaire sur mesure

Objectif Description d’une nouvelle procedure chirurgicale permettant la realisation d’une arthrodese circonferentielle et une fixation trans sacro-lombaire posterieure. Materiel and Methodes 6 patients âges de 13 a 19 ans ont ete operes selon cette technique. Tous etaient des spondylolisthesis de grade III ou IV de Meyerding. Il y avait 5 filles et un garcon. 4 patients etaient porteur d’une forme a sacrum vertical et 2 avaient une cyphose lombosacree normale. La technique comporte laminectomie sacree jusqu’en S2 est realisee. Puis une broche est ensuite placee medialement au travers des vertebres du bord posterieur de S2 jusqu’au coin antero-superieur de L5. La vis sur mesure, d’un diametre de 10mm est ensuite introduite en utilisant la broche comme guide. Une fois la fixation effectuee, la partie posterieure et superieure du sacrum est retiree et une double fusion inter-somatique est realisee. Il est ensuite effectue une fusion posterolaterale additionnelle. Resultats Aucune complication neurologique n’a ete notee. Une breche durale fut realisee durant la dissection et a necessitee une simple reparation. Tous les patients ont ete leves au cinquieme jour post operatoire avec reprise de la marche. Un corset hemi-culotte post-operatoire a ete porte pendant 4 mois pour 4 patients et pendant 2 mois pour les 2 derniers. La serie presentee a un recul moyen de 21mois, aucun des patients ne presente de symptomes en post operatoire. Unefois la fusion acquise, il existe un restitution de l’equilibre sagittal avec une lordose lombaire plus prononcee, une vertebre neutre et un point d’inflexion plus bas que lors de l’evaluation radiologique preoperatoire. Discussion Chez les enfants porteurs d’un spondylolisthesis de haut grade, le rachis lombaire s’adapte aux nouvelles conditions mecaniques. Le principal but du traitement est donc d’obtenir une fusion solide. Dans la technique que nous presentons, aucune reduction n’a ete realisee en dehors de celle obtenue lors du positionnement en decubitus ventral sur la table operatoire. La fusion circonferentielle est obtenue par une approche posterieure unique, evitant ainsi les risques inherents a un abord anterieur.

SOFOP-03 – Chirurgie orthopédique – Le synovialosarcome des membres de l’enfant : prise en charge chirurgicale

Introduction La prise en charge chirurgicale des synovialosarcomes des membres de l’enfant n’est pas systematisee. Nous souhaitons a partir d’une serie de douze cas, soulever les problemes poses par leurs orientations therapeutiques Materiel Il s’agit d’une analyse retrospective de 12 patients, d’age moyen 12 ans (5 ans a 18 ans), suivis avec un recul moyen de 6 ans 10 mois (20 mois a 13 ans). Les localisations etaient 5 cas au membre superieur (3 mains, 2 coudes) et 7 cas au membre inferieur (1 cas sur le col femoral, 1 cas sur la cuisse, 3 cas sur le genou extra articulaire, 1 cas sur le genou intra articulaire, 1 cas sur le pied). Methode Le bilan pre operatoire a comporte une IRM dans 9 cas sur 12. Le delai entre le debut des symptomes est de 11 mois. La biopsie a ete 6 fois intra tumorale et 6 fois sous forme d’exerese marginale. On retrouve 4 formes biphasiques, 6 tumeurs monomorphiques et 2 inclassees. Le traitement a toujours comporte une chimiotherapie dans les suites immediates de la biopsie. Une exerese carcinologique a ensuite ete realisee dans 6 cas. Une radiotherapie scondaire a ete effectuee dans 3 cas situes sur la main. Enfin dans 3 cas de biopsie – exerese marginale une radiotherapie de 45 grays a ete realisee sur un residu microscopique potentiel. Resultats Trois cas de recidive locale ont ete constates sur des localisations a la main. Il a alors ete effectue une amputation du rayon concerne. Aucune metastase a distance n’est a deplorer. On note cent pour cent de survie au dernier recul. Discussion et Conclusion La prise en charge chirurgicale du synovialosarcome des membres de l’enfant n’est pas consensuelle. La biopsie des formes de petite taille se resume souvent a une exerese marginale sans residu macroscopique. Lorsque la situation anatomique autorise une exerese en bloc non mutilante de la zone cicatricielle, celle-ci peut etre recommandee. En revanche, si l’exerese en bloc d’un residu tumoral potentiel impose des sacrifices majeurs et obere severement le pronostic fonctionnel, elle peut faire discuter une surveillance apres chimiotherapie et radiotherapie. L’absence de metastase a distance dans l’ensemble de la serie encourage les auteurs a poursuivre dans cette attitude.