Jérôme Cottalorda

Complications in pediatric spine surgery using the vertical expandable prosthetic titanium rib: the French experience.

Study Design. Multicenter retrospective study of 54 children. Objective. To describe the complication rate of the French vertical expandable prosthetic titanium rib (VEPTR) series involving patients treated between August 2005 and January 2012. Summary of Background Data. Congenital chest wall and spine deformities in children are complex entities. Most of the affected patients have severe scoliosis often associated with a thoracic deformity. Orthopedic treatment is generally ineffective, and surgical treatment is very challenging. These patients are good candidates for VEPTR expansion thoracoplasty. The aim of this study was to evaluate the potential complications of VEPTR surgery. Methods. Of the 58 case files, 54 were available for analysis. The series involved 33 girls and 21 boys with a mean age of 7 years (range, 20 mo–14 yr and 2 mo) at primary VEPTR surgery. During the follow-up period, several complications occurred. Results. Mean follow-up was 22.5 months (range, 6–64 mo). In total, 184 procedures were performed, including 56 VEPTR implantations, 98 expansions, and 30 nonscheduled procedures for different types of complications: mechanical complications (i.e., fracture, device migration), device-related and infectious complications, neurological disorders, spine statics disturbances. Altogether, there were 74 complications in 54 patients: a complication rate of 137% per patient and 40% per surgery. Comparison of the complications in this series with those reported in the literature led the authors to suggest solutions that should help decrease their incidence. Conclusion. The complication rate is consistent with that reported in the literature. Correct determination of the levels to be instrumented, preoperative improvement of nutritional status, and better evaluation of the preoperative and postoperative respiratory function are important factors in minimizing the potential complications of a technique that is used in weak patients with complex deformities. Level of Evidence: 4

Proximal femoral osteotomies in children

The aim of proximal femoral osteotomies (PFO) in children is to restore normal anatomy and optimal joint congruency to prevent medium and long-terms degenerative deterioration of the hip. They play an important role in the treatment of neurological subluxations or dislocations of the hip. Advances in modern imaging and surgical techniques have improved understanding of the anatomical factors associated with a number of disorders of the growing hip and their sequelae. The indications for isolated PFO or associated with other intra- or extraarticular procedures have become more rational and better adapted to the various architectural defects and the femoroacetabular impingements. Two types of osteotomies are described: intertrochanteric osteotomies (varus and valgus correction, valgisation, flexion, extension), and osteotomies of the greater trochanter, either simple or double with lengthening of the femoral neck. Primary stability of the osteosynthesis is the major problem, as it is often affected by osteopenia. The development of new implants (LCP plate) avoids this inconvenience, resulting in geometrically precise osteotomies and a more stable fixation. Even when it is correctly performed, articular congruence is not always managed by PFO alone, it is sometimes necessary to associate acetabular procedures.

Diagnosis and surgical treatment of dysplasia epiphysealis hemimelica. A report of nine cases

BACKGROUND Dysplasia epiphysealis hemimelica (DEH) is a rare developmental bone disorder with hemimelic involvement of one or more epiphysis. We report on nine new cases and discuss the clinical manifestations, the value of MRI, and the results of complete and early surgical resection of these lesions. MATERIALS AND METHODS In this retrospective study, nine patients with a diagnosis of DEH were evaluated. Age at presentation ranged from 1 year to 12 years. The main complaint at diagnosis was a swelling bony mass. Angular deformities were recorded in two patients. All patients were surgically treated and followed up clinically and by imaging. Eight patients underwent excision only. RESULTS The average follow-up was 5.6 years (range, 2-10.5 years). All patients had a good outcome without related symptoms. No epiphysiodesis, angular deformity or recurrence was observed. One patient with femoral lesion involving the distal medial part of the epiphysis developed, four months after surgical excision, a calcification outside the area of total excision. This calcification did not increase in size at two years follow-up. Another patient with lateral involvement of the proximal tibial epiphysis presented a postoperative nervous complication. Spontaneous nervous recovery occurred three months after surgery. DISCUSSION MRI was useful to find a potential plane of cleavage between the epiphysis and the pathological tissue. We recommend early removing ossifications when a cleavage plane is identified. Waiting a possible complication or increasing of size does not seem logical. Of course, the treatment will be not the same if no cleavage plane is found on MRI. LEVEL OF EVIDENCE IV.

Torticollis in Children: A Challenging Diagnosis of C1-C2 Septic Arthritis

The causes of torticollis are highly varied. In most cases, benign causes are found. However, other serious causes that require rapid diagnosis and treatment may be involved. We report here 4 cases of septic atlanto-axial arthritis in infants with torticollis. A search on PubMed using the keywords “atlanto-axial septic arthritis” or “C1-C2 septic arthritis” associated to “torticollis” could not find any pediatric case. We found only cases of “osteomyelitis of the odontoid” with torticollis. The aim of this study is to report this cause of cervical arthritis in children. We first describe in detail 4 observations of torticollis in children secondary to C1-C2 septic arthritis then discuss this issue.

Long-term Results After Extensive Soft Tissue Release in Very Severe Congenital Clubfeet.

Background: The purpose of this study was to determine the long-term results, at an average follow-up of 22 years, in 66 patients (105 clubfeet) with very severe congenital idiopathic clubfeet according to the Dimeglio-Bensahel scale. Methods: Patients were treated with an extensive soft tissue release in infancy. Results of the treatment were assessed according to the 100-point system of Ghanem-Seringe. At the latest follow-up, all participants were evaluated with regard to pain and the overall function of the lower extremities. At the latest follow-up, anteroposterior and lateral radiographs of the affected foot and the contralateral normal foot, when applicable, were performed. Results: In total, 92% of the patients were satisfied. The mean functional score of Ghanem-Seringe was 70.4 points. No foot had an excellent result, 19 feet had a good result, 16 had a fair result, and 70 had a poor result. A total of 86 feet were painful after strenuous activities or during walking. Eleven patients walked with a limp. In total, 82 feet were stiff. Ankle dorsiflexion and plantar flexion averaged 4.0±4.5 degrees and 19.9±10.7 degrees. Bone deformations such as flattening of the talar dome were observed in 93 feet. Among these feet, the Ghanem score was significantly lower (P<0.05). Necrosis of the navicular was present in 28 feet and subluxation in 82 feet. In total, 32 feet had moderate osteoarthritis. Discussion: Results revealed that despite anatomically and radiologically imperfect clubfeet, most patients demonstrated satisfaction. Satisfaction was not significantly correlated with residual deformity, but with the sensation of a normal gait by the patient and the high initial Dimeglio-Bensahel score. Female patients were significantly less satisfied than male patients because they were more constrained in their social life than boys. Their main dissatisfaction was the atrophy of the calf. We noted several residual deformations. Plantar release seems to contribute to the high rate of overcorrection in our series. Extensive posterolateral and plantar releases in very severe clubfeet was responsible for sequelae, morphologic, anatomic, and functional, especially in adulthood. Deterioration of results over time was confirmed by our series. Level of Evidence: Level IV.

Osteotomías del extremo proximal del fémur en pacientes pediátricos

Las osteotomias del extremo proximal del femur (OEPF) en ninos tienen como objetivo restablecer una anatomia lo mas parecida posible a la normalidad y una congruencia articular optima para prevenir los deterioros artrosicos de la cadera a medio y largo plazos. Siempre tienen un lugar importante en el tratamiento de las caderas neurologicas. Los progresos de las pruebas de imagen modernas y de las tecnicas quirurgicas han permitido una identificacion mejor de los factores anatomicos artrogenos responsables de un conflicto femoroacetabular en muchas afecciones de la cadera en crecimiento y sus secuelas. Las indicaciones de las OEPF, solas o asociadas a otros procedimientos extra y/o intraarticulares, son mas racionales y mejor adaptadas a los distintos vicios estructurales y a los conflictos femoroacetabulares. Se distinguen tres tipos de osteotomias: las osteotomias intertrocantereas (varizacion, valguizacion, flexion, extension), las osteotomias simples del trocanter mayor o dobles con efecto de alargamiento del cuello femoral y las osteotomias del cuello femoral. Su principal problema reside en la estabilidad primaria de la osteosintesis, aumentado en ocasiones por la osteoporosis, en particular en las enfermedades neurologicas o las enfermedades oseas constitucionales. Sin embargo, siempre se debe tener en cuenta la cadera en su conjunto porque las OEPF, incluso cuando se realizan a la perfeccion, son a veces insuficientes para optimizar la congruencia articular. Dado que la cavidad cotiloidea rodea la esfericidad de la cabeza femoral durante todo el crecimiento, es mas logico asociar procedimientos acetabulares a estas osteotomias. Todos los cirujanos ortopedicos deben conocer adecuadamente las tecnicas quirurgicas de estas osteotomias.

Osteotomie dell’estremità superiore del femore nei bambini

Riassunto Le osteotomie dell’estremita superiore del femore (OESF) nei bambini hanno come obiettivo ristabilire un’anatomia il piu possibile simile a quella normale e una congruenza articolare ottimale, al fine di prevenire i deterioramenti artritici dell’anca a medio e lungo termine. Esse rivestono sempre un ruolo importante nel trattamento delle anche neurologiche. I progressi dell’imaging moderno e delle tecniche chirurgiche hanno permesso una migliore identificazione dei fattori anatomici artrogeni responsabili del conflitto femoro-acetabolare in numerosi disturbi dell’anca in crescita e relative conseguenze. Le indicazioni delle OESF, sole o associate ad altri interventi extra- e/o intra-articolari, sono quindi piu razionali e meglio si adattano ai diversi vizi architettonici e ai conflitti femoro-acetabolari. Si possono distinguere tre tipi di osteotomie: le osteotomie intertrocanteriche (varizzazione, valgizzazione, flessione, estensione), le osteotomie semplici del grande trocantere o doppie con effetto di allungamento del collo del femore, e le osteotomie del collo del femore. Il loro problema principale e rappresentato dalla stabilita primaria dell’osteosintesi, aggravata talvolta dall’osteoporosi, in particolare nelle malattie neurologiche o nelle malattie ossee costituzionali. Tuttavia, occorre sempre prendere in considerazione l’anca nel suo insieme in quanto le OESF anche se perfettamente eseguite sono talvolta insufficienti per ottimizzare la congruenza articolare. Poiche la matrice cotiloidea detiene la sfericita della testa del femore durante tutta la sua crescita, e piu logico associarvi degli interventi acetabolari. Le tecniche chirurgiche di tali osteotomie devono essere ben conosciute da ogni chirurgo ortopedico.

Small bone islands: unusual clinical symptomatology.

Bone islands are usually considered benign, stable, nonprogressive lesions, radiographically characterized by an ovoid, round, or oblong homogeneously dense and sclerotic focus in the spongiosa, with a preference for the long bones and the pelvis. Benign solitary bone islands are usually believed to be asymptomatic, with no necessity for treatment. Symptomatic bone islands reported in the literature are characterized by a diameter greater than 2 cm, belonging to the category of giant bone islands. The authors report a rare case starting from a painful symptomatology and involving dense sclerotic bone lesions of less than 2 cm, thus falling into the category of small bone islands. The patient underwent a surgical resection to achieve complete recovery. Normally, small bone islands do not explain the pain in patients who present with symptomatology when they are detected during radiographic studies. Based on this case, the authors believe that even small bone islands can be the cause of symptomatology and justify a surgical procedure if all medical investigations suggest no other possible causes of the pain.

New Concept for Correction of Brachymetatarsy by 3D CT-Scan Measurement

We reported progressive metatarsal lenghtening by external fixator after osteotomy by open approach without bone interposition in a case of brachymetatarsia upon the third and fourth metatarsals. After a tomodensitometry planification, the biometry of the five metatarsal bones was done by X-ray and CT scan by measuring each metatarsal length (1 to 5) in the sagittal, horizontal and coronal plans and angles. The average amount of lengthening was 17 mm for the third and 15 mm the fourth at the end, 40% of the original length (range, 36 to 44%). In the same time, we treated hallux valgus by osteotomy. Decrease of motion and joint deformity did not occur. The control of the CT scan allowed choosing the real orientation and length of the two metatarsal bones to obtain an adequate parabola. Measurements with CT scan were more reliable than Xray.

Chapitre 17 – Fractures des deux os de l'avant-bras

Introduction  Les fractures de l’avant-bras sont classiquement représentées par les fractures atteignant simultanément les deux os, ou séparément, chacun d’eux. Le plus souvent les 2 os sont fracturés  Les fractures diaphysaires d’un seul os s’accompagnent volontiers de lésions ligamentaires et articulaires affectant les extrémités de l’os voisin, définissant ainsi :  Fractures de Monteggia : fracture de l’ulna et luxation de la tête radiale  Fractures de Galeazzi : fracture du radius et dislocation de l’articulation radio-ulnaire distale  En mettant en cause les mouvements de prono-supination, ces différentes lésions ont la réputation d’un pronostic fonctionnel réservé