Kamel Ayadi

Les luxations traumatiques de la hanche chez l’enfant

PURPOSE OF THE STUDY Traumatic hip dislocation is a rare event in children. Appropriate management remains a subject of debate. The purpose of this study was to investigate the epidemiological, therapeutic features of this situation and the long-term outcome after treatment. MATERIAL AND METHODS This was a retrospective analysis of 15 traumatic hip dislocations collected over a period of 20 years in pediatric patients with at least two years follow-up. We searched for predisposing factors and factors affecting prognosis. RESULTS The series included 11 boys and three girls, mean age eight years. Dislocation was posterior in 13 hips and anterior in two. Time to reduction was less than 3h in eight cases, 3-6h in five and greater than 6h in two. After reduction, traction was performed in nine children, for 20 days on average, followed in five cases by immobilization for 40 days on average. Five hips were immobilized directly after reduction. We identified two groups by age: group 1 with dislocations in children aged less than six years (seven children) were characterized by low-energy trauma. Dislocation was not associated with other lesions. Predisposing factors (overt ligament hyperlaxity, insufficient superolateral head cover, coax valga) were noted in six children. Reduction was simple. Later treatment consisted in immobilization with a pelvispedious cast for 30-45 days. Group 2 were dislocations in children aged over six years (seven children) victims of high-energy trauma. Associated injuries were frequent. Predisposing factors were not present. At mean 11 years follow-up, all hips are considered normal clinically. The radiograph was normal for 14 hips. In one case, there was a slight coax magna. In three patients, defective femoral head cover persisted. Coxa valga persisted in two patients. DISCUSSION Traumatic dislocation of the hip joint is rare in very young children, but results from a minimally traumatic event. This suggests the presence of predisposing factors in this category of patients, particularly capsuloligamentary hyperlaxity. After reduction, immobilization can be recommended. Traumatic hip dislocations in children are different from the adult variety due to their rarity, the general absence of associated fractures, easy reduction and better prognosis. The epidemiological and therapeutic features in children older than six years are however similar to those in adults.

A Review of Ewing Sarcoma Treatment: Is it Still a Subject of Debate?

BACKGROUND The Ewing sarcoma (ES) represents 10 to 15% malignant bone tumors and 40 to 45% pediatric malignant bone tumors. The aim of this review is to clarify the therapeutic results and prognostic factors of this entity. METHODS A systematic review of the literature was performed. Studies focused on the management of ES were considered for inclusion. RESULT ES represents a model of multidisciplinary approach. The optimization of ES multimodality therapeutic strategies has resulted from the efforts of several national and international groups in Europe and North America and from cooperation between the pediatric and medical oncologists. The overall 5- year survival of Ewing localized tumors was 70% versus 30% in metastatic ES. CONCLUSION The treatment of ES includes neoadjuvant and adjuvant chemotherapies with surgery and/or radiotherapy for control of the primary site and possible metastatic disease. The role of high-dose chemotherapy is still debated.

Manifestations orthopédiques de la neurofibromatose de Von Recklinghausen

OBJECTIVE Von Recklinghausens neurofibromatosis is a dominant autosomic genetic disease characterized by different clinical manifestations. The goal of this work was to study its orthopaedic manifestations and to show the characteristics of their management. METHOD A retrospective study was carried out on 15 patients having a Von Recklinghausens neurofibromatosis. For each patient, different orthopaedic manifestations and their evolution after treatment were analyzed. These manifestations were classified in spinal deformities, pseudarthrosis of long bones and tumours of the peripheral nerves. RESULTS The spinal deformities were observed in 9 cases. A dystrophic scoliosis was observed in 6 patients with an average angle of 50° and was associated to a kyphosis in 5 patients. The treatment was surgical by posterior arthrodesis in 2 cases and circumferential arthrodesis in 2 cases. The congenital curves and pseudarthroses of leg were observed in 5 cases, localized at the lower third of the leg in all cases. An Ilizarov external fixator with segmental osseous transport was carried out in 2 patients. The duration of the external fixator was 23 months ½ with 5 interventions in each case. Four plexiform neurofibromas and 3 nodular neurofibromas were observed. A transformation into neurofibrosarcoma was found in 2 patients. In one case, a resection without functional sacrifice was carried out and in the other case the patient was dead before the resection. CONCLUSION The orthopaedic manifestations of Von Recklinghausens neurofibromatosis are frequent, varied and have a difficult management. The functional and sometimes vital prognoses are challenging.

Luxation septique de la hanche secondaire à la vaccination par le BCG

Resume Les auteurs rapportent un cas de luxation septique de la hanche chez un nourrisson de 8 mois, secondaire a une vaccination par le BCG. Le traitement habituel d’une arthrite septique comportant un drainage chirurgical et une antibiotherapie a large spectre n’a pas ete suffisant. C’est a la suite de sa mise sous traitement anti-tuberculeux et d’un deuxieme drainage chirurgical que la guerison a ete obtenue. Cette complication rare du BCG, peut survenir plusieurs mois apres l’administration du vaccin; elle est de diagnostic souvent difficile au vu du caractere fruste et non specifique des signes cliniques et radiologiques au debut et les difficultes de mise en evidence du germe responsable. Le diagnostic de certitude est souvent apporte par la biopsie et l’examen anatomo-pathologique. Malgre la virulence attenuee du germe, un traitement anti-tuberculeux est indispensable pour assurer la guerison; le drainage chirurgical seul est insuffisant.

Les lésions nerveuses dans les fractures supra- condyliennes de l'humérus chez l'enfant

Resume La fracture supra-condylienne de l’humerus est de loin la plus frequente des fractures du coude chez l’enfant et la plus pourvoyeuse de complications nerveuses. Notre objectif est d’etudier le profil clinique et evolutif de ces lesions nerveuses. Nous avons etudie l’evolution de l’atteinte nerveuse chez 55 enfants. II s’agissait de 28 paralysies du nerf radial, 20 paralysies du nerf median et 7 paralysies du nerf ulnaire. Dans 32 cas, la lesion nerveuse a ete diagnostiquee avant le traitement alors que dans 23 cas, elle a ete decouverte apres le traitement. Pour les lesions nerveuses diagnostiquees avant le traitement, la recuperation a ete spontanement complete dans tous les cas et dans un delai maximal de 4 mois. Alors que pour les lesions decouvertes apres le traitement, la recuperation spontanee a ete obtenue dans 20 cas. Le delai de recuperation a ete de moins de 4 mois dans 12 cas et entre 5 et 10 mois dans 8 cas. Les 3 autres ont necessite une exploration nerveuse avec une neurolyse dans deux cas et une greffe nerveuse dans 1 cas. Dans le deuxieme groupe, la lesion nerveuse est soit causee, soit aggravee par le traitement. Ceci souligne la necessite de rechercher minutieusement une lesion nerveuse meme incomplete devant toute fracture supra-condylienne du coude chez l’enfant et la plus grande douceur lors de la reduction de ces fractures meme si l’examen initial ne met pas en evidence de lesion nerveuse.Purpose of the study The most frequent type of elbow fracture in children is by far the supracondylar fracture. This type of fracture also raises the greatest risk of nerve injury. We wanted to study the clinical and prognostic features of nerve injuries in children presen-ting supracondylar fractures of the humerus.

Localisation épiphysaire de la tuberculose

Introduction : nous rapportons un cas de tuberculose de l’epiphyse femorale inferieure ayant un aspect radiographique caracteristique d’un chondroblastome. Methodes : il s’agissait d’un garcon de 8 ans qui a consulte pour gonalgies droites depuis 3 mois, avec notion de traumatisme du pied il y a 1 mois. A l’examen, ce garcon etait apyretique, il marchait avec discrete boiterie droite. Le genou n’avait pas de signes inflammatoires et pas de choc rotulien, sa mobilite etait normale et il y avait des douleurs moderees du bord interne du genou. Le bilan biologique a montre une VS a 14, fibrinemie a 2.2, CRP et Latex Waler-Rose negatifs. La radiographie a montre une lacune epiphysaire sous chondrale du condyle femoral interne. A l’IRM, elle faisait 16*11 mm, en hyposignal T1 et hypersignal T2 avec important œdeme perilesionnel qui prend le contraste. Le diagnostic de chondroblastome a ete evoque et une biopsie a ete realisee par un abord direct Trans-cartilagineux. Resultats : Le tissu preleve etait puriforme et le diagnostic d’osteomyelite subaigue etait evoque. L’examen anatomopathologique a confirme le diagnostic de tuberculose. Il n’y avait pas d’autres localisations tuberculeuses et l’enfant a ete mis sous antituberculleux. Au recul de 2 ans, l’enfant est asymptomatique et on a constate un comblement progressif de la lesion epiphysaire. Conclusion : La tuberculose doit etre evoquee devant toute lesion epiphysaire solitaire de l’enfant. Elle vient en 3eme position apres l’osteomyelite et le chondroblastome.

[Orthopaedic manifestations of Von Recklinghausen's neurofibromatosis].

OBJECTIVE Von Recklinghausens neurofibromatosis is a dominant autosomic genetic disease characterized by different clinical manifestations. The goal of this work was to study its orthopaedic manifestations and to show the characteristics of their management. METHOD A retrospective study was carried out on 15 patients having a Von Recklinghausens neurofibromatosis. For each patient, different orthopaedic manifestations and their evolution after treatment were analyzed. These manifestations were classified in spinal deformities, pseudarthrosis of long bones and tumours of the peripheral nerves. RESULTS The spinal deformities were observed in 9 cases. A dystrophic scoliosis was observed in 6 patients with an average angle of 50° and was associated to a kyphosis in 5 patients. The treatment was surgical by posterior arthrodesis in 2 cases and circumferential arthrodesis in 2 cases. The congenital curves and pseudarthroses of leg were observed in 5 cases, localized at the lower third of the leg in all cases. An Ilizarov external fixator with segmental osseous transport was carried out in 2 patients. The duration of the external fixator was 23 months ½ with 5 interventions in each case. Four plexiform neurofibromas and 3 nodular neurofibromas were observed. A transformation into neurofibrosarcoma was found in 2 patients. In one case, a resection without functional sacrifice was carried out and in the other case the patient was dead before the resection. CONCLUSION The orthopaedic manifestations of Von Recklinghausens neurofibromatosis are frequent, varied and have a difficult management. The functional and sometimes vital prognoses are challenging.

Article originalManifestations orthopédiques de la neurofibromatose de Von RecklinghausenOrthopaedic manifestations of Von Recklinghausen's neurofibromatosis

OBJECTIVE Von Recklinghausens neurofibromatosis is a dominant autosomic genetic disease characterized by different clinical manifestations. The goal of this work was to study its orthopaedic manifestations and to show the characteristics of their management. METHOD A retrospective study was carried out on 15 patients having a Von Recklinghausens neurofibromatosis. For each patient, different orthopaedic manifestations and their evolution after treatment were analyzed. These manifestations were classified in spinal deformities, pseudarthrosis of long bones and tumours of the peripheral nerves. RESULTS The spinal deformities were observed in 9 cases. A dystrophic scoliosis was observed in 6 patients with an average angle of 50° and was associated to a kyphosis in 5 patients. The treatment was surgical by posterior arthrodesis in 2 cases and circumferential arthrodesis in 2 cases. The congenital curves and pseudarthroses of leg were observed in 5 cases, localized at the lower third of the leg in all cases. An Ilizarov external fixator with segmental osseous transport was carried out in 2 patients. The duration of the external fixator was 23 months ½ with 5 interventions in each case. Four plexiform neurofibromas and 3 nodular neurofibromas were observed. A transformation into neurofibrosarcoma was found in 2 patients. In one case, a resection without functional sacrifice was carried out and in the other case the patient was dead before the resection. CONCLUSION The orthopaedic manifestations of Von Recklinghausens neurofibromatosis are frequent, varied and have a difficult management. The functional and sometimes vital prognoses are challenging.

A rare Wilkins group II fracture of the proximal radial metaphysis.

In this study, we report a rare fracture of the proximal radial metaphysis in an 11-year-old child, involving an anterior displacement of the proximal radial metaphysis instead of a displacement of the epiphysis, which preserved its normal connections with the capitellum. This fracture was successfully treated by closed reduction and wire fixation. The reduction maneuver attempted to reduce the proximal radial metaphysis under the epiphysis instead of doing the opposite. The mechanism of this injury is probably an extension strain on a forearm in pronation associated with a violent contraction of the biceps brachialis muscle. This fracture is considered as a rare example of Wilkins group II angular fracture of the proximal radial metaphysis, without proximal ulnar fracture.

Results of surgical treatment of congenital convex pes valgus (ten nonidiopathic feet)

PURPOSE OF THE STUDY Congenital pes valgus is a rare and complex deformity of the foot raising serious diagnostic and therapeutic challenges. The purpose of our work was to present the surgical procedures used in our series and to analyze outcome. MATERIAL AND METHODS Ten feet presenting congenital convex pes valgus treated surgically over a six-year period using the same operative technique were reviewed at minimum five years follow-up. Idiopathic deformities were excluded from this series. Deformities were secondary to arthrogryposis in five feet, multiple malformative syndrome in four, and diastematomyelia in one. The surgical technique used two approaches: a posteromedial incision to release the dorsal flexors, disinsert the tibialis posterior, open the talonavicular joint, release the Achilles tendon and release the posterior tibiotalar capsule; a lateral incision to lengthen the fibular tendons and perform an osteotomy of the anterior process of the calcaneum. A talonavicular pin and a calcaneocuboid pin maintained the correction. The tibialis posterior tendon was reinserted on the anterior aspect of the talonavicular capsule after incision of the dislocation chamber. RESULTS Outcome was considered good in five cases and fair in five. Outcome was fair in the arthrogryposis feet. Under correction was observed in two feet and valgus flatfoot in three. Talar necrosis occurred in one foot and navicular necrosis in two. DISCUSSION Simultaneous correction of the different anomalies observed in the congenital convex foot was achieved in this series. The anatomic and functional results were satisfactory. We recommend avoiding overly extensive release in order to decrease the risk of talar and navicular necrosis. It is also important to check the reduction radiographically during the operation. Patients should use an orthesis for several months postoperatively to avoid recurrence.