Frank Fitoussi

Kinematic analysis of the upper limb: a useful tool in children with cerebral palsy

Upper limb involvement in cerebral palsy is usually more complex than lower limb involvement. Each child has a specific brain lesion and the clinical pattern is highly variable. Current clinical methods of assessment do not fully evaluate the kinematic activity during simple activities of daily life. We defined an upper limb three-dimensional kinematic protocol in order to complete the clinical analysis of such patients and reproducibility tests are in progress. Data were presented for one of the patients studied and showed some important differences between the clinical analysis and the kinematic one. A three-dimensional upper limb motion analysis gives a more complete kinematic evaluation and should help better measure the results of treatments.

Thenar flap for severe finger tip injuries in children

Twelve children aged between 18 months and 11 years old who had sustained a severe fingertip amputation with total or subtotal pulp loss were treated with a distal-based thenar flap. The injuries were palmar oblique amputations or avulsion injuries involving the pulp and the nail bed. The pedicles of the thenar flaps were divided after 18 to 25 days and none suffered any necrosis. At the final follow-up, no interphalangeal joint contractures were found, the average two point discrimination was 5 mm, the thenar scar was asymptomatic and the subcutaneous tissue of the thenar flap was providing sufficient bulk to produce a rounded contour, like a normal fingertip. The thenar flap is a useful technique for use with severe fingertip injuries when local flaps cannot provide enough soft tissue and replantation is not possible.

Is the Induced-membrane Technique Successful for Limb Reconstruction After Resecting Large Bone Tumors in Children?

BackgroundResection of primary malignant tumors often creates large bony defects. In children, this creates reconstructive challenges, and many options have been described for limb salvage in this setting. Studies have supported the use of an induced-membrane technique after placement of a cement spacer to aid in restoration of bone anatomy.Questions/purposesWe asked: (1) What complications are associated with the induced-membrane technique? (2) How often is bone healing achieved after resection greater than 15 cm using this technique? (3) What is the functional outcome of patients treated with this technique?MethodsWe performed a retrospective evaluation of eight patients with a mean age of 13.3 years (range, 11–17 years) treated for a malignant bone tumor between 2002 and 2012 at our centers. The primary malignant tumors involved the proximal humerus, femur, and tibia. All patients were treated using the induced-membrane technique after a resection with mean bone loss of 18 cm (range, 16–23 cm). The general indication for using the induced-membrane technique during this time was a large diaphyseal defect after resection of the tumor. In addition to using cancellous graft as with the original technique, in the current patients an autogenous nonvascularized fibula was used to enhance stability. The patients were assessed at the last followup using the Musculoskeletal Tumor Society (MSTS) scoring system. Mean followup was 47.1 months (range, 24–120 months), and none of the patients were lost to followup before 2 years.ResultsA total of four unplanned reoperations were performed in these eight patients. A fracture of the reconstruction occurred in three patients and all were treated successfully, two with surgery and one with immobilization. Bone fusion was obtained in all patients within 4 to 8 months (mean, 5.6 months) after the reconstruction. The mean healing index was 0.31 month/cm of reconstruction (range, 0.23–0.5 month/cm). At last followup, the mean MSTS score was 74% (range, 67%–80%).ConclusionsOur findings suggest that the modified induced-membrane technique is a reasonable alternative to other limb reconstruction techniques for bone tumors in children and has the advantage of not requiring a bone bank or an expensive metal prosthesis. Although more patients will be needed to substantiate our findings, it has become a standard part of our arsenal in the treatment of large bone defects after resection of pediatric primitive bone tumors.Level of EvidenceLevel IV, therapeutic study.

Extensor Tendon Injuries in Children

Introduction: This study retrospectively analyzes primary extensor tendon repairs in children younger than 15 years. Methods: Exclusion criteria were skin loss, devascularization, fractures, or flexor tendon injuries. Fifty patients who had sustained extensor tendon laceration with 53 digits injured were available for review. Treatment consisted of primary repair of the extensor tendon injury within the first 24 hours. The results were assessed by means of total active motion system and by Millers rating system. The mean follow-up was 2 years. Results: Although 98% of the digits were rated as good or excellent according to the total active motion system and 95% according to Millers classification, 22% of the fingers showed extension lag or loss of flexion at the last follow-up. Discussion: Pejorative influencing factors were injuries in zones I, II, and III; children younger than 5 years (P < 0.05), and complete tendon laceration. Articular involvement had no significant influence on final outcome.

Case Reports: Treatment of Traumatic Triradiate Cartilage Epiphysiodesis: What is the Role of Bridge Resection?

BackgroundAcetabular fractures are rare in children and can be complicated by premature fusion of the triradiate cartilage resulting in secondary acetabular dysplasia. Early recognition and treatment of a physeal bar in this location can be difficult. The purpose of this case report was to investigate whether early intervention could restore acetabular growth and prevent secondary acetabular dysplasia as measured on plain radiographs.Case DescriptionWe report a series of three patients (3, 4, and 5 years old) who underwent physeal bridge resection and methylmethacrylate or fat interposition through an extended Pfannenstiel approach. The mean followup was 6 years. After resection of the osseous bridge the physis initially remained open with evident acetabular growth in all three patients. In one patient, the bridge reformed 6 years after the procedure. All patients had a slight increase in the thickness of the acetabular wall relative to the contralateral side but no radiographic evidence of acetabular dysplasia.Literature ReviewTo our knowledge, there are only two reports of physeal arrest resection of triradiate cartilage with one successful result.Clinical RelevancePosttraumatic, partial physeal arrest of the triradiate cartilage may be treated with resection of the bone bridge resection through an extended Pfannenstiel approach. The potential benefits of this treatment must be weighed against the risks.

Shoulder external rotator selective neurotomy in cerebral palsy: anatomical study and preliminary clinical results.

Shoulder external rotation posturing in patients with cerebral palsy can severely impair bimanual activities and lead to painful shoulder instability. We performed an anatomical study to describe the surgical approach to the shoulder external rotators nerves. Using this technique, we performed a selective neurotomy in five shoulders with external rotator shoulder spasticity. Ashworth scale dropped from 2 or 3 to 0 and active internal rotation increased from 0–10 to 60–70°. This is a short series but preliminary results are encouraging and allow us to extend the study to a greater number of patients.

Distally based sural flap for ankle and foot coverage in children.

BACKGROUND Coverage of soft-tissue defects of the ankle and foot is often challenging. The distally based sural fascio-cutaneous flap is useful for reconstructing the lower leg, ankle, heel, and foot but has rarely been evaluated in paediatric patients. The objectives of this study were to assess the reliability of this flap in paediatric patients, to describe the complications associated with its use, and to define its indications in paediatric patients with soft-tissue defects of the ankle and foot. HYPOTHESIS We hypothesised that the sural flap was reliable for covering soft-tissue defects at the ankle and foot in paediatric patients. MATERIAL AND METHODS A distally based sural fascio-cutaneous flap was used to cover soft-tissue defects of the ankle and foot in 20 paediatric patients between 1997 and 2013. The evaluation at last follow-up included a physical examination and determination of the modified functional Kitaoka score. Mean follow-up was 50.6 months (range, 10-192 months) and mean patient age at surgery was 8.8 years (range, 1.5-17 years). Trauma was the most common cause of soft-tissue defect (n=12); other causes were surgical-site infections (n=2), tumours (n=3), chronic ulcer (n=1), burn injury (n=1), and infusion fluid extravasation (n=1). RESULTS Of the 20 flaps, 16 (80%) remained fully viable, whereas 4 developed partial necrosis requiring excision and skin grafting, which consistently ensured a good outcome. Other complications consisted of marginal necrosis (n=4), unsightly donor-site scars (n=5), and infection (n=2). Abnormal flap sensation was noted in 11 patients. The mean modified Kitaoka score was 65/80 (range, 0-80), and the score value indicated that function was excellent in 9 (45%) patients, good in 9 (45%) patients, and poor in 2 (10%) patients. DISCUSSION The distally based sural fascio-cutaneous flap is a method of choice for covering soft-tissue defects of the ankle and foot in paediatric patients. This reliable flap spares the major blood vessels and has a strong blood supply. Its best indication is coverage of an acute traumatic soft-tissue defect with exposure of a vital structure. In patients requiring late reconstruction, caution is in order when considering the use of a distally based sural fascio-cutaneous flap, which can induce delayed complications, most notably at the donor site. LEVEL OF EVIDENCE IV, retrospective case-series study.

Isolated C5-C6 avulsion in obstetric brachial plexus palsy treated by ipsilateral C7 neurotization to the upper trunk: outcomes at a mean follow-up of 9 years.

Cervical root avulsions are the worst pattern of injury in obstetrical brachial plexus injury (OBPI). The prognosis is poor and the treatment is mainly surgical with extraplexual neurotizations or muscle transfers. We present the outcomes of a technique performed in our institution to treat C5–C6 avulsion in obstetrical brachial plexus injury. This technique consists of a total ipsilateral C7 neurotization to the upper trunk. Ten babies with isolated C5–C6 root avulsion were operated on; we were able to review nine of them at over 12 months follow-up. The shoulder and the elbow function were assessed, as well as the Mallet Score. The mean follow-up was 9.2 years (SD 5.7). After a follow-up of 6 years, elbow flexion was restored with a range of motion ⩾130° and a motor function ⩾M3 in all patients. The average Mallet score was 18.1 (SD 1.2). This approach appears to be a viable alternative to extraplexual neurotizations for the treatment of C5–C6 nerve root avulsion.

Treatment of severe radial club hand by distraction using an articulated mini-rail fixator and transfixing pins

INTRODUCTION Treatment of severe radial club hand is difficult. Several authors have emphasized the importance of preliminary soft-tissue distraction before centralization. HYPOTHESIS Treatment of severe radial club hand by articulated mini-rail allowing prior soft-tissue distraction improves results. MATERIAL AND METHODS Thirteen patients were treated sequentially, with an initial step of distraction and a second step of centralization. The first step consisted in fitting 2 mini-fixators, one in the concavity and the other in the convexity of the deformity. Four transfixing wires through the ulna and metacarpal bone connected the 2 fixators. After this preliminary distraction, the fixator was removed and a centralization wire was introduced percutaneously, with ulnar osteotomy if necessary. Sagittal and coronal correction was measured on the angle between forearm and hand. RESULTS Mean age at treatment was 37.5 months (range, 9-120 months). Mean distraction time was 53.2 days (26-90 days). Ulnar osteotomy was required in 8 cases (61%). There were no major complications requiring interruption of distraction. Sagittal and coronal correction after centralization reduced mean residual forearm/hand angulation to<12°. DISCUSSION Soft-tissue distraction in the concavity ahead of centralization is essential to good correction, avoiding extensive soft-tissue release and hyperpressure on the distal ulnar growth plate. There have been several studies of distraction; the present technique, associating 2 mini-fixators connected by threaded K-wires, provided sufficient distraction in the concavity of the deformity to allow satisfactory correction in all cases. Subsequent complications (breakage or displacement of the centralization wires) testify to the complexity of long-term management. CONCLUSION The present study confirms the interest of a preliminary soft-tissue distraction step in treating severe radial club hand.

Hematogenous osteoarticular infections of the hand and the wrist in children with sickle cell anemia: preliminary report.

Background: Hematogenous osteoarticular infections of the hand and the wrist in children with sickle cell anemia are rare and no specific studies for this location have been published. Methods: This retrospective and comparative study reviewed 34 children who carry the diagnosis of osteoarticular infections of the wrist and the hand at our institution during a 10-year period extending from January 2000 to December 2010. The first group included 8 patients with sickle cell anemia (Hg SS). The second group or control group included 26 children without sickle cell disease or any immune deficiency. Differences between groups were established by &khgr;2 tests. Results: The most common site of osteomyelitis for the sickle cell group was the metacarpals and the fingers phalanx (87.5%) whereas the most common site for the control group was the wrist and the carpus (96.2%; P<0.005).The most common pathogens responsible for osteomyelitis was Salmonella sp. (37.5%) for children with SCD, whereas it was Staphylococcus aureus (70%) for the nonsicklers. There was a significant difference between both groups regarding the treatment. Indeed, a surgical procedure was needed for the sickle cell group in all cases (100%) whereas a surgical debridement was needed in only 19.2% patients in the control group (P<0.001). At long-term follow-up, there were more long-term complications in the sickle cell group (62.5%) with epiphysiodesis of the metacarpals and metacarpophalangeal joint destruction whereas only 11.5% cases with complications were present in the control group including distal ulna epiphysiodesis, proximal interphalangeal joint stiffness, and a central radius epiphysiodesis (P<0.004). Conclusions: Our results confirm the severity of hand osteomyelitis in patients with sickle cell disease. A systematic approach is needed to perform early diagnosis and treatment. Identification of the causative organism is required (blood culture, bone aspiration). With antibiotic therapy, surgical treatment is the rule. Parents have to be advised about frequent complications like shortening or deformation due to premature fusion. Level of Evidence: Level III.