Guy Fabry

Torsion of the Femur

A twenty-year follow-up on the use of the Dunlap-Shands method for the determination of torsion of the femur is presented, with the results of a total of 1,990 torsion studies in normal children and children with congenital dislocation of the hip, coxa plana, toeing-in, and cerebral palsy. The effect of increased anteversion is discussed as it relates to each hip condition discussed. Increased anteversion should be considered a very significant factor in the treatment of many hip conditions.

The effects of quantitative gait assessment and botulinum toxin a on musculoskeletal surgery in children with cerebral palsy

BACKGROUND The limits of nonoperative treatment for children with cerebral palsy, including physical therapy and orthotics, commonly lead to orthopaedic surgical intervention. The purpose of the present study was to evaluate the influence of gait analysis and botulinum toxin type-A injections on the timing, prevalence, and frequency of orthopaedic surgery. METHODS We performed a retrospective review of 424 children with cerebral palsy who had been born between 1976 and 1994. The children were divided into three groups: Group 1 comprised 122 patients who were managed throughout the entire study period according to best-practice guidelines in orthopaedics, Group 2 comprised 170 patients who were similarly managed but with input from gait analysis, and Group 3 comprised 132 patients who had gait analysis and also received botulinum toxin type-A injections. We analyzed the prevalence of orthopaedic surgical procedures at different ages (three to nine years) and the time to the first surgical procedure. RESULTS The progression to orthopaedic surgery was significantly different among the three groups (p < 0.0001). The proportion of patients who had undergone at least one surgical procedure by the age of seven years was 52% (sixty-four of 122) for Group 1, 27% (forty-six of 170) for Group 2, and 10% (thirteen of 132) for Group 3. There was a delay in surgery in Group 2 as compared with Group 1 (p < 0.00001 at seven, eight, and nine years of age) and a significant decrease in the prevalence of orthopaedic surgical procedures for Group 3 as compared with Group 1 (p < 0.00001 at four to eight years of age) and Group 2 (p < 0.0025 at four to nine years of age). CONCLUSIONS In the treatment of children who have cerebral palsy, the introduction of gait analysis increases the age of the first orthopaedic surgical procedure and botulinum toxin type-A treatment delays and reduces the frequency of surgical procedures.

Distraction bone healing versus osteotomy healing: a comparative biochemical analysis.

This study investigates the biochemical changes in a canine tibia lengthening model in comparison with a nonlengthened osteotomy model. The lengthened and the osteotomized callus and a contralateral corresponding segment were analyzed for their mineralization profile, collagen content, osteocalcin, insulin‐like growth factor I (IGF‐I), and transforming growth factor β1 (TGF‐β1). Examinations of bone samples were performed using specimens excised at different time intervals (respectively at 3, 5, 7, 9, and 13 weeks postoperatively). Several serum parameters (alkaline phosphatase [ALP], osteocalcin, IGF‐I, and TGF‐β1) were also measured during the experimental period. A progressive increase in mineral parameters was noticed in both the lengthened and the osteotomized areas. A higher level of hydroxyproline and TGF‐β1 was observed in the lengthened area compared with the osteotomized area. IGF‐I showed a significant increase in both the lengthened and contralateral control area at the later stage of the experimental period in the lengthened group. In serum, a high level of TGF‐β1 and a progressively increasing osteocalcin concentration were observed in the lengthened dogs in comparison with the osteotomized dogs. Serum ALP was significantly increased in both models during the experimental period. Serum IGF‐I was increased in the lengthened models during the distraction period and decreased in the osteotomized models at the early stage of the experimental period. These results suggest that the mechanical strain induced by the Ilizarov distraction procedure stimulates osteoblast proliferation and promotes biosynthesis of bone extracellular matrix in distracted callus. Our data furthermore show that this process is different compared with normal fracture healing.

Arthroscopic suturing of TFCC lesions

Different types of triangular fibrocartilage complex (TFCC) lesions have been described. We propose an arthroscopic repair of the peripheral tear, as it is a tear in the vascular portion of the TFCC. The technique is based on one used for meniscal repairs of the knee, and it is quite easy to perform.

The Results of Carpal Tunnel Release: Open Versus Endoscopic Technique

We retrospectively compared two similar groups of patients who underwent either endoscopic decompression of the carpal tunnel (single portal technique, 44 patients) or open decompression (58 patients) during 1 year in our department. To find out whether there was any subjective difference between the results of the two techniques, we sent each patient a questionnaire and received a 95% response. No major complications occurred. Three endoscopic decompressions had to be abandoned, and open release was performed. We could not demonstrate any significant difference in relief of symptoms and return to work between the two groups. Patient satisfaction at 6 to 18 months follow-up was high with both techniques.

Negative ulnar variance is not a risk factor for Kienböck's disease.

Ulnar variance was measured in standardized conditions in 125 normal wrists and in 52 patients with Kienböcks disease. No significant difference in ulnar variance between a sex/age-matched control group and a group of patients affected with Kienböcks disease was found. A positive correlation was found between age and ulnar variance. No significant difference was found between men and women. Based on these results, negative ulnar variance does not seem to be an important factor in the etiology of Kienböcks disease.

Subacromial impingement: Open versus arthroscopic decompression

An analysis of the follow-up results of 53 patients treated by an arthroscopic decompression (AD) and 53 patients treated by an open decompression (OD) is presented. Patients were evaluated pre- and postoperatively with the UCLA Shoulder Rating Scale, which includes an assessment of pain, function, range of motion, strength, and patient satisfaction. After an average of 20.1 months for the AD group and 27.3 months for the OD group, good or excellent results were found in 83.1% in the AD group and in 81.1% in the OD group. Patient satisfaction was 88.3% (AD) compared with 94.3% (OD). Results of decompression in both groups were not influenced by associated pathologies (acromioclavicular degeneration, frozen shoulder, calcified tendinitis, rotator cuff lesions).

Normal and abnormal torsional development in children.

This study presents findings in a series of 123 children with intoeing gait. The intoeing was caused by increased femoral anteversion (IFA) in 70% of the cases, and internal tibial torsion (ITT) in 30%. Rotation of the hips, thigh-foot angle, Q-angle, and computed tomography measured anteversion and tibial torsion divided the two groups very clearly. In the IFA group, 40.3% of the patients presented with an externally rotated tibia and 59.7% had an internally rotated tibia. In the ITT group, the anteversion was normal for age and the tibial torsion was significantly decreased. Eighty children who corrected their intoeing gait, and of whom 83.4% had IFA, were also reviewed: a decrease in anteversion was observed in 20.5% of the patients; 62.9% showed no decrease in anteversion.

Allograft Versus Autograft Bone in Idiopathic Scoliosis Surgery: A Multivariate Statistical Analysis

The use of autograft versus allograft bone in scoliosis surgery is critically evaluated by a multivariate statistical analysis. Two groups of patients matched for age, angle of curve, and length of fusion, forming a consecutive series of posterior arthrodesis for idiopathic scoliosis, were evaluated. Group A consisted of 83 patients receiving autografts, and group B consisted of 99 patients receiving allografts. There was a significant reduction in operation time in the allograft group, and blood loss also decreased. After 1 year there was no significant difference in correction of the curve. Given the problems of discomfort at the donor site scar, we recommend the use of allograft bone in scoliosis surgery.

Motor function following multilevel botulinum toxin type A treatment in children with cerebral palsy

This study evaluated the effects of multilevel botulinum toxin type A (BTX‐A) treatments on the gait pattern of children with spastic cerebral palsy (Gross Motor Function Classification System Levels I‐III). In this nested case—control design, 30 children (mean age 6y 11mo [SD 1y 5mo]; 21 males, nine females; 19 with hemiplegia, 11 with diplegia) were treated according to best practice guidelines in paediatric orthopaedics, including BTX‐A injections. A matched control group of 30 children (mean age 7y 8mo [SD 1y 10mo]; 13 males, 17 females; 19 with hemiplegia, 11 with diplegia) were treated identically, but without BTX‐A. Motor development status at 5 to 10 years of age was assessed by means of three‐dimensional gait analysis at a mean time of 1 year 10 months (SD 10mo) after the last BTX‐A treatment. The control group showed a significantly more pronounced pathological gait pattern than the BTX‐A group. Major differences were found for pelvic anterior tilt, maximum hip and knee extension, and internal hip rotation. These results provide evidence for a prolonged effect of BTX‐A and suggest that BTX‐A injections, in combination with common conservative treatment options, result in a gait pattern that is less defined by secondary problems (e.g. bony deformities) at 5 to 10 years of age, minimizing the need for complex surgery at a later age and enhancing quality of life.