Jean-Marc Guillaume

Is there a place for patellofemoral arthroplasty

Indications for patellofemoral arthroplasty were studied based on a 2− to 10-year followup review. Of 183 patellofemoral prostheses implanted between 1980 and 1990,104 were associated with unicompartmental arthroplasty, and 79 were implanted alone. Thirteen patients were lost to followup. The results of 66 patellofemoral arthroplasties are reported at an average followup of 66 months. The mean age of the patients at surgery was 57 years. Underlying causes of the osteoarthritis included patellar dislocation or dysplasia (22), patellar fracture (20), and primary osteoarthritis (24). A metallic femoral groove was associated with a polyethylene patella with no metal backing. Two (9%) prostheses were revised in the dysplasia group, 1 (5%) in the posttraumatic group, and 7 (29%) in the primary osteoarthritis group. In this latter group, the indications of patellofemoral arthroplasty must be restricted to lesions of the patellofemoral joint in a knee in neutral axis evaluated preoperatively on full standing and stress radiographs. The best results of patellofemoral arthroplasty were obtained in osteoarthritis after patellar dislocation or patellar fracture.

Surgical management of type II tibial intercondylar eminence fractures in children.

The objective of this study was the evaluation of the therapeutic options in type II tibial intercondylar eminence fractures. Seventeen children were treated surgically. Open reduction, curettage of the fracture area and internal fixation were performed. The average follow-up was 3 years. No reduction in sport activities or instability have been noted. The average Lysholm score was 99.7 at the latest follow-up. We recommend the surgical procedure for type II tibial intercondylar eminence fractures in children. Surgical treatment with the curettage of the fracture area limits risks of residual knee laxity and could improve the risks of arthritis decompensation and meniscus lesion at long-term follow-up.

Classification of chance fracture in children using magnetic resonance imaging.

Study Design. MRI study of pediatric Chance fracture. Objective. To evaluate bone and soft tissue lesions in pediatric Chance fracture. Summary of Background Data. Several descriptions and classifications have been already developed for Chance fracture, but mainly for adult. Furthermore, they are all based only on radiographic studies. Methods. MRI and radiographs of 18 children with Chance fracture were analyzed before treatment. Results. On MRI, in all cases, no abnormal signs were noted on the intervertebral disc. Six patients had a bone fracture going through the pedicle and the vertebral body. Twelve patients had a physeal injury located on the superior or on the inferior vertebral endplate. Three types of lesions could be identified according to the location of the lesion in relation to the pedicle. Conclusion. MRI is useful in the diagnosis of pediatric Chance fracture. It allows physeal injury to be clearly identified from disc injury.

Hip Flexion Contracture and Lumbar Spine Lordosis in Myelomeningocele

The objective of this study was to assess the correlation between hip flexion contracture (HFC) and the sagittal alignment of the lumbar spine in ambulatory children with myelomeningocele. Ambulatory patients with myelomeningocele are generally free of scoliosis or kyphosis. Among them, some develop increased lumbar lordosis. It is postulated that HFC and increased lumbar lordosis may be correlated. Thirty-eight patients, with a mean age of 12.7 years, were evaluated. Standing lateral spine films were obtained and the lumbar lordosis was measured using the Cobb method. HFC was measured using the Thomas test. A statistically significant correlation was found between the lumbar curve and HFC. High values of lumbar Cobb angle (hyperlordosis) were correlated with high values of HFC. These results show a correlation between HFC and increased lumbar lordosis in ambulatory myelomeningocele patients.

Dermo-hypodermite nécrosante compliquant la varicelle chez l'enfant sous anti-inflammatoires non stéroïdiens : À propos de 2 cas

We report two cases of fasciitis with necrotizing hypodermitis of the foot and arm which complicated varicella in immunocompetent children given nonsteroidal anti-inflammatory drugs. The skin barrier and immune function are weakened by the varicella zoster virus. Exposure to nonsteroidal anti-inflammatory drugs further favors necrotizing cutaneous infections caused by group A beta hemolytic streptococci. MRI can confirm the presence of superficial aponevrosis necrosis defining necrotizing fasciitis but should not retard surgical management which is always indicated for necrotizing fasciitis and sometimes for necrotizing dermo-hypodermitis.Resume Nous rapportons deux cas de fasciite avec dermo hypodermite necrosante du pied et du bras compliquant la varicelle d’enfants immunocompetents mis sous anti-inflammatoires non steroidiens. L’effraction de la barriere cutanee, l’alteration des fonctions immunitaires par le virus VZV et l’exposition aux anti inflammatoires non steroidiens favorisent les infections cutanees necrosantes a streptocoque beta hemolytique du groupe A. L’IRM peut affirmer la necrose de l’aponevrose superficielle, qui definit la fasciite necrosante. Toutefois, elle ne doit pas retarder la prise en charge chirurgicale toujours indiquee en cas de fasciite necrosante et parfois necessaire dans les dermo-hypodermites necrosantes.

Growth plate behavior after desepiphysiodesis: experimental study in rabbits.

The aim of this work was to study the potential healing of the growth plate in the case of a central desepiphysiodesis. A central defect was made in the distal femoral growth plate of thirty 3-week-old rabbits. In group A the growth plate defect was left empty as control. The defects of group B were implanted with a polymeric cylinder fixed in the metaphysis with a pin. In group C the cylinder was fixed in the epiphysis. Two months after implantation, clinical, radiologic, and histologic analyses were carried out. In group A, the mean shortening was 12.63%; it was 4.9% in group B and 1.54% in group C. Histologic analysis showed constant appearance of an epiphysiodesis after migration of the implant in the metaphysis. No regeneration of the growth plate was observed. Prevention of migration of the interpositional material is recommended to avoid recurrence of an epiphysiodesis.

Progressive anterior vertebral bars a study of 16 cases

Study Design. In a retrospective study, we report on 16 patients with congenital kyphosis due to progressively ossifying anterior unsegmented bars. Objective. To specify the therapeutic strategy in such malformation. Summary of Background Data. Congenital kyphosis due to progressively ossifying anterior unsegmented bars is a particular and uncommon entity of congenital kyphosis. Progressive anterior vertebral bars result in slowly progressive kyphosis, which rarely lead to neurological compromise. Sagittal equilibrium of the spine is maintained by compensatory curves adjacent to the primary curve. Methods. All patients had clinical assessment and successive measurements of segmental angle made on a standing lateral radiograph of the spine. Magnetic resonance imaging was obtained in four patients. Six patients were just observed. A brace was used in three. And seven were treated surgically. Results. The compensatory capacity of the spine is reduced in lumbar area where there are few discs spaces below the bar. Presentation therefore tends to be at an earlier age and pain is more common. Magnetic resonance imaging enables definition of the structures immediately posterior to the bar and provides information regarding the integrity of the intervertebral disc. Conclusion. There is usually no need for surgery in thoracic and thoracolumbar localization. In lumbar localization, if the diagnosis is done early in childhood and if magnetic resonance imaging shows beyond the anterior ossification a normal T2-weighted magnetic resonance imaging disc space signal, desepiphysiodesis bar resection and cement interposition is mandatory. If the disc magnetic resonance imaging signal is abnormal or if the disc space is totally ossified, we propose a surgical correction of the kyphosis. For such cases a posterior wedge osteotomy seems to be the more suitable procedure.

Genu Valgum in Legg-Calvé-Perthes Disease Treated with Femoral Varus Osteotomy

AbstractFemoral varus osteotomy is one of the most common treatments for patients with symptomatic Legg-Calvé-Perthes disease with more severe deformities. We hypothesized knee valgus alignment at maturity in patients with Legg-Calvé-Perthes disease is an effect of the disease and not an effect of femoral varus osteotomy. We retrospectively compared matched groups of 28 patients with and without femoral varus osteotomy. The two groups were similar with respect to age at onset and classification of Herring et al. The distribution of valgus alignment among patients who had surgery and patients who did not have surgery was assessed at maturity and was similar between the operative and nonoperative groups. The data suggest valgus malalignment (genu valgum) is not a side effect of femoral varus osteotomy in patients with Legg-Calvé-Perthes disease, but rather an effect of the disease. Level of Evidence: Level III, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Progressive forearm lengthening with an intramedullary guidewire in children: report of 10 cases.

Indications for forearm lengthening are rare. Between 1994 and 1999, 10 forearm lengthenings were performed in seven children for functional reasons and/or esthetic discomfort. Only one of the two forearm bones was involved in the procedure in all cases. The technique consisted of a transverse osteotomy and progressive distraction after intramedullary nailing. When a bone axis correction was needed, it was performed with a substraction osteotomy in the initial osteotomy site. The distraction device was removed when bone healing was achieved. The authors noted the various complications and assessed the amount of elongation, bone healing, and potential bone axis deviation. Mean follow-up was 4.5 years. Mean elongation was 30.8 mm. Four bone grafts were needed for delayed union. No bone axis deviation was noted. An initial axial correction osteotomy allows an easier lengthening procedure. Use of an intramedullary wire avoids axis deviation. This technique can be helpful in malformative pathologies.

Fractures-décollements épiphysaires de type Salter II de l’extrémité distale du fémur chez l’adolescent : nouvelle proposition thérapeutique (étude préliminaire)

PURPOSE OF THE STUDY The prognosis of distal femoral physeal fracture-separation is poor in children. In adolescents, more than half of the cases are classified as Salter and Harris type-II. The gold-standard treatment for a displaced fracture combines anatomic reduction with internal fixation with a pin or screw, preserving the growth cartilage. Despite this treatment, the rate of mid- and long-term complications has been high in the literature, most problems being related to leg length discrepancy and misalignments (genu valgum and genu varum). In order to avoid these problems, for adolescents, we propose and osteosynthesis system which bridges the entire growth cartilage with a blade-plate. Depending on the bone age, puberty and thus potential for further growth, we combine this osteosynthesis with a contralateral distal femoral epiphysiodesis to prevent invalidating leg length discrepancy. MATERIAL AND METHODS We reviewed retrospectively the cases of 21 patients aged 11 to 15 years treated between 1990 and 2005 for Salter and Harris type-II distal femoral physeal fracture- separation. Clinical and radiographic outcome was compared between the 16 patients treated with the classical internal fixation system or cast immobilization and the five patients treated with a blade-plate. A complete physical examination was available for the follow-up in all cases. A full stance view was used for the radiographic analysis. The mean follow-up was 6.7 years (range 2-17), minimal two years. RESULTS In patients treated with the classical fixation system or a plaster cast, four of 16 (25 %) developed frontal misalignment of more than 5 degrees and five of 16 (32 %) leg length discrepancy of more than 2cm. No misalignment or leg length discrepancy (>2cm) was observed among the five patients treated with a blade-plate. DISCUSSION The results observed in our patients treated with the classical fixation systems are comparable with those reported by others. Our patients treated with the blade-plate system constitute the only series with no cases of frontal misalignment or invalidating leg length discrepancy after this type of fracture. We used contralateral distal femoral epiphysiodesis in all patients whose predictable leg length discrepancy at the end of growth was greater than 2cm, that is 11-3.5 years (bone age) in girls and 13-14.5 years in boys. CONCLUSION Internal fixation techniques bridging the growth cartilage are the only techniques used for Salter and Harris type-II distal femoral physeal fracture-separation in adolescents which have been able to prevent posttraumatic knee misalignment (genu valgum or genu varum). Leg length discrepancy can be prevented by a contalateral distal femoral epiphysiodesis when the fracture occurs in a child or early puberty.