Ismat Ghanem

Epidemiology, etiology, and genetic aspects of reduction deficiencies of the lower limb

Although the majority of lower limb deficiencies are of sporadic occurrence and of unknown etiology, genetic factors are involved in a significant number, with variable modes of inheritance. A better-informed public is demanding advice concerning cause and recurrence. Careful scrutiny of the medical history and family tree and attention to phenotypic details may help to delineate entities. At times, specific chromosomal tests are important, mainly when there is bilateral or multiorgan involvement or when limb deficiency is associated with developmental delay and/or mental retardation. This paper is intended to refamiliarize the orthopaedic community with basic genetic aspects regulating reduction deficiencies of the lower limbs, and to emphasize on the importance and indications of genetic counseling.

Fait cliniqueBursite bicipitoradiale de l’adolescent : une entité rare pouvant simuler une tumeur maligneAdolescent bicipitoradial bursitis: A rare disease that can simulate a malignant tumor

Bicipitoradial bursitis is a rare condition: we found 36 cases reported in the literature, none in children. The main manifestation is a painful tumefaction. We report a case observed in an adolescent whose magnetic resonance imaging findings were compatible with a malignant tumor. Surgical biopsy enabled the correct diagnosis of inflammatory synovium without signs of malignancy compatible with bicipitoradial bursitis. Complete cure was achieved without resection.

Bone healing is achievable despite extensive wound dehiscence and wide plate and screws exposure in children

BACKGROUND Extensive wound dehiscence and wide plate and screw exposure in the early weeks following orthopaedic surgery in children is usually managed either by extensive debridement, lavage and secondary closure or hardware removal and external fixation. PATIENTS Three children with LCP plate and screws exposure were managed by simple repetitive debridement and local wound care without any IV antibiotics, nor secondary closure or hardware removal. All three cases occurred in the tibia, one following tibial osteotomy in lateral hemimelia with a long history of previous surgeries, one following wide excision of a tibial Ewing sarcoma with chemo- and radiotherapy, and the third following wide excision of a 12cm necrotic tibial segment due to chronic osteomyelitis. Bone healing was uneventful in 2 cases and was in progress in the case with the Ewing sarcoma. Plate and screws were removed in all cases, following an obvious bone healing in 2 cases, and forced by the need for chemotherapy due to the presence of lung metastases in the third case. Spontaneous soft tissue healing occurred thereafter. CONCLUSION A stable fixation may lead to a good bone healing despite an extensive wound dehiscence and a wide plate and screws exposure with just a proper local wound care and without any major additional surgery. LEVEL OF EVIDENCE Level IV.

Varus producing osteotomy for patients with lateral pillar type B and C Legg-Calve-Perthes disease followed to skeletal maturity. Castaneda et al. JCOR (2008), 2:373-379.

Dear Editors, I read the paper by Castaneda et al. about LCP with great interest. In the paper’s introduction section, the authors state that “many of the concepts regarding the disease have not evolved in almost a century.” This is quite unfortunate indeed, and I fully agree with them. The study is well conducted, and the paper is well written. However, I would be less affirmative in stating that femoral varus osteotomy (FVO) achieves similar results to non-operative treatment in Herring B and C. Their findings may not necessarily support this conclusion. The fact that both treatments lead to almost similar results, even slightly worse in the surgically treated group, do not mean that one should observe severely involved Perthes hips and never take them to surgery, be it pelvic or femoral. Important clinical and radiological information is necessary to support their statement and is missing from their paper. Although classification according to Caterall and/or Herring certainly has a prognostic implication, other factors play a major role in determining outcome and are certainly used for decision making by a vast majority of pediatric orthopedic surgeons around the globe. The Iowa hip score and the Stulberg classification were used in this study to determine the outcome at final follow-up, but no information is given to the reader concerning preoperative clinical and radiological differences (other than the Herring classification) between both groups, mainly those related to hip motion, hinge abduction, and the severity of femoral head extrusion or subluxation. Severity of involvement should not only be decided based on the height of the lateral pillar, as we all know. Two hips classified as Herring C may behave completely differently and lead to different outcomes following operative or non-operative treatments. In fact, one could assume that cases where FVO was performed were clinically and radiographically initially more severe with obvious and progressive lack of containment compared to cases where non-operative management was decided upon and undertaken. From another angle, why did the physicians who chose to treat Herring C hips nonsurgically decide to do so, and why did those who operated on similar hips (based only on the classification) decide to do so? In my perspective, viewed from this angle, a similar outcome in both groups could rather be seen as being in favor of performing FVO in severely affected and subluxed hips, as it may improve the hip situation to a point where it becomes similar to those hips that do not need surgery. This is an issue that I was just discussing with some colleagues who had the same impression after reading the manuscript, and I wanted to share it with you and the authors. I am sure that they have conducted and worked out this study so well that the information I am asking for can be easily made available, maybe as a basic criteria for further studies and publications on such a mysterious and controversial disease. Once again, I would like to congratulate the authors for this long-term, well-conducted and well-written study, and I thank them in advance for their answer. Sincerely, Ismat Ghanem

Prothèse totale du genou assistée par ordinateur

PURPOSE OF THE STUDY Conventional techniques proposed for total knee arthroplasty (TKA), necessarily require an acceptable alignment of the lower limb. Computer-assisted surgery is becoming increasingly popular in order to improve the precision of the component alignment, an essential element for good long-term results. The purpose of this prospective study was to present our preliminary results with computer-assisted implantation of TKA. MATERIAL AND METHODS This was a prospective study of 55 patients (60 knees) included at random for computer-assisted TKA between April 2004 and September 2005. Mean age was 70.5 years. The preoperative assessment noted genu varum in 56 knees and genu valgum in four knees. Three knees with unilateral degenerative disease presented a post traumatic tibia malunion. The same surgeon performed all of the operations using the same prosthesis and navigation system (P.F.C. Sigma). Lower limb alignment and orientation of the prosthetic implants were assessed with standard pre- and postoperative gonometry. Sagittal alignment was measured on the standard X-rays (lateral and anteroposterior view). RESULTS Knee alignment improved from 8.1+/-4.5 degrees varus (10 degrees valgus to 18 degrees varus) preoperatively, to 0.4+/-0.6 degrees varus (1 degrees valgus to 2 degrees varus) postoperatively. In the frontal plane, the mean angle of the femoral component on the anteroposterior (ap) view was 89.7+/-0.7 degrees (88-91 degrees). The mean angle of the tibial component on the ap view was 89.9+/-0.7 degrees (88.5-91 degrees). The femorotibial mechanical axis was within +/-2 degrees for all prostheses. In the sagittal plane, the mean angle of the femoral component on the lateral view was 4.8 degrees (3-6.5 degrees). The mean tibial slope was 2.7 degrees (1-4 degrees) for the prostheses with a fixed tibial plateau and 0.2 degrees (-1 degrees to +1 degrees) for those with a rotating plateau. The mean operative time was 135 min (110-180 min) and was inversely proportional to experience. There was one conversion to conventional surgery due to software dysfunction. There were no complications related to the operative technique. DISCUSSION The best outcome, particularly in terms of aseptic loosening, is reported for knees with a valgus or varus angle within 3 degrees . The improved accuracy of computer-assisted implantation has enabled better orientation of the components in the frontal, sagittal and horizontal planes with implantations well within this range.