P. Darodes

Natural course of osteochondritis dissecans in children.

Results are reported from an absence of physiotherapic, orthopaedic, or surgical treatment in 31 cases of osteochondritis dissecans in 24 children. The mean age at diagnosis was 11 years and 4 months, and all the children were suffering from pain for an average of 3 months. None of these children were treated, except for instructions to discontinue involvement in sports activities until their pain had disappeared. In all cases pain disappeared, and these children have all returned to their former activities. According to x-ray findings, 30 lesions disappeared totally, although there was one case of a loose body. As a result, absence of treatment is recommended for osteochondritis dissecans in children.

Ulnar styloid fracture in children: a retrospective study of 46 cases.

Ulnar styloid fractures are frequently ignored in the treatment of wrist fractures in children. Forty-six untreated ulnar styloid fractures (40 tip and six base fractures) associated with radial injuries (45 patients) were retrospectively analysed. At the removal of the cast, we recorded that 80% had a nonunion of the styloid fracture. Thirty-five patients were reviewed at an average of 19 months after treatment. Thirty tip fractures and five base avulsions were found. We recorded 28 patients with a good clinical result despite 21 cases of nonunion, whereas seven patients (all nonunions) had a fair result. All the fair results suffered from intermittent pain during sports and movement, radioulnar joint instability and tears of the triangular fibrocartilage complex. It can be concluded that both distal radius and ulnar styloid fractures should be taken into account in the initial treatment and pain associated with a nonunion of the ulnar styloid in a child may be due to a tear of the triangular fibrocartilage complex.

Arthrolyse antérieure de l'épaule sous arthroscopie dans les séquelles de paralysie obstétricale du plexus brachial. Résultats préliminaires

PURPOSE OF THE STUDY Retraction of the shoulder in internal rotation is observed in 25% of children with brachial plexus birth palsy (C5, C6 +/- C7). Early bone and joint deformities affecting the glenohumeral joint are the consequences. The stiff internal rotation requires surgical release which can involve the capsule and ligaments, muscles, or both. Internal release can be combined with muscle transfer to improve active external rotation. We report the results obtained with arthroscopic anterior capsular release combined with latissimus dorsi transfer. MATERIAL AND METHODS From 1999 through 2006, fourteen children with a stiff shoulder in internal rotation secondary to brachial plexus birth palsy were managed in our unit. All had recovered biceps function six months after surgery. The glenohumeral dysplasia was analyzed on the preoperative magnetic resonance imaging. Pre- and postoperative passive external rotation (RE) were measured with the arm along the body and at 90 degrees elbow flexion. Internal rotation was measured using the Mallet score (hand-back test). Combined active abduction antepulsion was measured when the child was playing. Mean age at surgery was three years six months. Arthroscopic internal release was performed for eight children. All had an associated latissimus dorsi transfer. RESULTS Among the 14 children managed in the unit, arthrolysis was not be performed in six, either because of the lack of an adequate electrode (two patients) or because the child presented posterior glenohumeral dislocation making it impossible to introduce the optic channel (four patients). Arthroscopic anterior release was performed for the eight other patients. These eight patients were reviewed at a mean three-year follow-up. Passive external rotation was improved, with a mean gain of 60 degrees with no recovery of passive internal rotation. The abduction antepulsion movement was also improved, mean gain 90 degrees . DISCUSSION A stiff shoulder in internal rotation can develop during the first two years of life. Several techniques have been proposed for internal release. The origin of the progressive limitation of passive external rotation remains a subject of debate. Is it due to retraction of the internal rotators, or to capsule-ligament retraction, or both? In 1992, Harryman et al. demonstrated the role of the capsule and the coracohumeral ligament in limiting external rotation. Consequently, we have opted for early release (less than two years of age) using an arthroscopic method limited to the capsule and ligaments. Our results for passive external rotation are comparable to those reported by others. However, this technique enables preserved mobility for internal rotation. CONCLUSION Arthroscopic anterior release limited to the capsule and the ligaments is an effective, minimally invasive technique. Leaving the internal rotator muscles intact preserves internal rotation of the shoulder and reduces the risk of anterior instability.

Reconstruction osseuse des os longs après exérèse carcinologique par l’utilisation de greffons fibulaires vascularisés chez l’enfant et l’adolescent

PURPOSE OF THE STUDY The vascularized fibular graft is a widely used technique for the reconstruction of long bone defects after tumor resection. Complications are not uncommon despite the presence of a good vascular supply. We report our experience with long bone reconstructions in children and adolescents after resection of primary malignant bone tumors. MATERIAL AND METHODS This retrospective analysis included thirteen patients aged 4-17 years (mean age 12 years). Preoperatively, the pathological diagnosis was Ewing tumor (n=7), osteogenic sarcoma (n=5), neuroepithelioma (n=1). All patients except one were given chemotherapy preoperatively and postoperatively and four received adjuvant radiotherapy. Tumor resection created a gap (n=8) or involved resection-arthrodesis (n=5, three knees, one ankle, one elbow). All reconstructions used a vascularized fibular flap with a complementary corticocancellous autograft for seven. RESULTS Complete carcinological resection was achieved in all cases. Mean follow-up was 50 months (range 12-144 months). There were no cases of local recurrence. Three patients presented lung metastasis; two patients died. Eleven of the twelve patients who underwent tumor resection involving the lower limb were able to walk with full weight bearing at 13.9 months (range 841 months), half of them without any supportive device. The MSTS score was 21/30 (range 7-29). Both ends healed for eleven of thirteen grafts. Outcome was good in four cases at 7.7 months (range 6-11), fair in seven (with 1-5 complementary procedures) at 14.8 months (range 10-45) and poor in two (nonunion at last follow-up). Among the fibular grafts which healed, primary healing of the distal end was noted in all cases, but not for the proximal end. Significant transplant hypertrophy was noted in 62% of patients, measured at mean 77.1% (range 25-128%). Complications were: skin necrosis (n=2), nonunion (n=4, three aseptic and one septic), disassembly (n=3 with two transplant fractures), and spontaneous fracture which healed (n=5, all but one treated orthopedically). There were four donor site complications: retraction of the hallux flexor (n=3), regressive paresia of the common fibular nerve (n=1). DISCUSSION The rate of healing in this series was similar to earlier reports. Healing was always achieved for the distal focus but not for the proximal focus which receives its blood supply from a branch of the anterior tibial artery which is not harvested. The defective blood supply can thus hinder bone healing. It is necessary to spare the proximal quarter of the fibula or harvest a bipediculated graft. The rate of graft hypertrophy was also similar, as was the rate of complications. The MSTS score was lower due to the poor results obtained with resection-arthrodesis of the knee joint. Graft fractures and aseptic nonunion are the most common complications but septic complications are more serious and can threaten graft survival. Complications at the donor site are exceptional. CONCLUSION Long bone reconstruction using an autologous vascularized fibular graft is a reliable technique providing satisfactory functional results. Complications can be prevented by making solid fixation and using a corticocancellous graft creating a favorable osteoinducing environment. A massive allograft is another solution providing good immediate mechanical stability.Resume La technique des greffons fibulaires vascularises fait partie de l’arsenal therapeutique des reconstructions des pertes de substance osseuse apres exerese tumorale. Nous rapportons notre experience concernant cette technique chez l’enfant apres resection carcinologique de tumeurs osseuses primitives malignes. Il s’agit d’une serie retrospective de 13 patients d’âge moyen 12 ans (4-17) comportant : 7 tumeurs d’Ewing, 5 osteosarcomes, un neuroepitheliome. Tous les patients (sauf un) ont beneficie d’une chimiotherapie pre et postoperatoire et 4 d’une radiotherapie adjuvante. Nous avons realise une reconstruction par fibula vascularisee a pedicule fibulaire, associee 7 fois a une autogreffe cortico-spongieuse, apres 8 resections intercalaires et 5 resection-arthrodeses. L’exerese carcinologique a toujours ete complete. Au recul de 50 mois (12-144), il n’y avait aucune recidive locale. Trois patients ont presente des metastases pulmonaires ; deux etaient decedes. Onze patients sur les douze operes au membre inferieur marchaient en plein appui a 13,9 mois (8-41) dont la moitie sans aucun appareillage. Le score MSTS etait de 21/30 (7-29). Onze transplants sur treize etaient solides aux deux extremites : 4 bons resultats a 7,7 mois (6-11), 7 moyens (une a 5 interventions supplementaires) a 14,8 mois (10-45) et 2 mauvais (non consolides). Tous les foyers fibulaires distaux ont consolide en premiere intention, a la difference des foyers proximaux. L’hypertrophie du transplant etait significative dans 62 % des cas, en moyenne 77,1 % (25-158). Les complications denombrees ont ete : 2 necroses cutanees, 4 pseudarthroses (3 aseptiques et une septique), 3 demontages (2 fractures du transplant) et 5 fractures spontanees, toutes traitees orthopediquement (sauf une) et ayant consolide. Quatre complications ont ete observees au site donneur : 3 retractions du flechisseur de l’hallux, une paresie regressive du nerf fibulaire commun.

MémoireReconstruction osseuse des os longs après exérèse carcinologique par l’utilisation de greffons fibulaires vascularisés chez l’enfant et l’adolescent: À propos d’une série de 13 cas à 50 mois de recul moyenReconstruction of long bone defects with a vascularized fibular graft after tumor resection in children and adolescents: thirteen cases with 50-month follow-up

PURPOSE OF THE STUDY The vascularized fibular graft is a widely used technique for the reconstruction of long bone defects after tumor resection. Complications are not uncommon despite the presence of a good vascular supply. We report our experience with long bone reconstructions in children and adolescents after resection of primary malignant bone tumors. MATERIAL AND METHODS This retrospective analysis included thirteen patients aged 4-17 years (mean age 12 years). Preoperatively, the pathological diagnosis was Ewing tumor (n=7), osteogenic sarcoma (n=5), neuroepithelioma (n=1). All patients except one were given chemotherapy preoperatively and postoperatively and four received adjuvant radiotherapy. Tumor resection created a gap (n=8) or involved resection-arthrodesis (n=5, three knees, one ankle, one elbow). All reconstructions used a vascularized fibular flap with a complementary corticocancellous autograft for seven. RESULTS Complete carcinological resection was achieved in all cases. Mean follow-up was 50 months (range 12-144 months). There were no cases of local recurrence. Three patients presented lung metastasis; two patients died. Eleven of the twelve patients who underwent tumor resection involving the lower limb were able to walk with full weight bearing at 13.9 months (range 841 months), half of them without any supportive device. The MSTS score was 21/30 (range 7-29). Both ends healed for eleven of thirteen grafts. Outcome was good in four cases at 7.7 months (range 6-11), fair in seven (with 1-5 complementary procedures) at 14.8 months (range 10-45) and poor in two (nonunion at last follow-up). Among the fibular grafts which healed, primary healing of the distal end was noted in all cases, but not for the proximal end. Significant transplant hypertrophy was noted in 62% of patients, measured at mean 77.1% (range 25-128%). Complications were: skin necrosis (n=2), nonunion (n=4, three aseptic and one septic), disassembly (n=3 with two transplant fractures), and spontaneous fracture which healed (n=5, all but one treated orthopedically). There were four donor site complications: retraction of the hallux flexor (n=3), regressive paresia of the common fibular nerve (n=1). DISCUSSION The rate of healing in this series was similar to earlier reports. Healing was always achieved for the distal focus but not for the proximal focus which receives its blood supply from a branch of the anterior tibial artery which is not harvested. The defective blood supply can thus hinder bone healing. It is necessary to spare the proximal quarter of the fibula or harvest a bipediculated graft. The rate of graft hypertrophy was also similar, as was the rate of complications. The MSTS score was lower due to the poor results obtained with resection-arthrodesis of the knee joint. Graft fractures and aseptic nonunion are the most common complications but septic complications are more serious and can threaten graft survival. Complications at the donor site are exceptional. CONCLUSION Long bone reconstruction using an autologous vascularized fibular graft is a reliable technique providing satisfactory functional results. Complications can be prevented by making solid fixation and using a corticocancellous graft creating a favorable osteoinducing environment. A massive allograft is another solution providing good immediate mechanical stability.Resume La technique des greffons fibulaires vascularises fait partie de l’arsenal therapeutique des reconstructions des pertes de substance osseuse apres exerese tumorale. Nous rapportons notre experience concernant cette technique chez l’enfant apres resection carcinologique de tumeurs osseuses primitives malignes. Il s’agit d’une serie retrospective de 13 patients d’âge moyen 12 ans (4-17) comportant : 7 tumeurs d’Ewing, 5 osteosarcomes, un neuroepitheliome. Tous les patients (sauf un) ont beneficie d’une chimiotherapie pre et postoperatoire et 4 d’une radiotherapie adjuvante. Nous avons realise une reconstruction par fibula vascularisee a pedicule fibulaire, associee 7 fois a une autogreffe cortico-spongieuse, apres 8 resections intercalaires et 5 resection-arthrodeses. L’exerese carcinologique a toujours ete complete. Au recul de 50 mois (12-144), il n’y avait aucune recidive locale. Trois patients ont presente des metastases pulmonaires ; deux etaient decedes. Onze patients sur les douze operes au membre inferieur marchaient en plein appui a 13,9 mois (8-41) dont la moitie sans aucun appareillage. Le score MSTS etait de 21/30 (7-29). Onze transplants sur treize etaient solides aux deux extremites : 4 bons resultats a 7,7 mois (6-11), 7 moyens (une a 5 interventions supplementaires) a 14,8 mois (10-45) et 2 mauvais (non consolides). Tous les foyers fibulaires distaux ont consolide en premiere intention, a la difference des foyers proximaux. L’hypertrophie du transplant etait significative dans 62 % des cas, en moyenne 77,1 % (25-158). Les complications denombrees ont ete : 2 necroses cutanees, 4 pseudarthroses (3 aseptiques et une septique), 3 demontages (2 fractures du transplant) et 5 fractures spontanees, toutes traitees orthopediquement (sauf une) et ayant consolide. Quatre complications ont ete observees au site donneur : 3 retractions du flechisseur de l’hallux, une paresie regressive du nerf fibulaire commun.

Reconstruction osseuse des os longs après exérèse carcinologique par l’utilisation de greffons fibulaires vascularisés chez l’enfant et l’adolescent: À propos d’une série de 13 cas à 50 mois de recul moyen

PURPOSE OF THE STUDY The vascularized fibular graft is a widely used technique for the reconstruction of long bone defects after tumor resection. Complications are not uncommon despite the presence of a good vascular supply. We report our experience with long bone reconstructions in children and adolescents after resection of primary malignant bone tumors. MATERIAL AND METHODS This retrospective analysis included thirteen patients aged 4-17 years (mean age 12 years). Preoperatively, the pathological diagnosis was Ewing tumor (n=7), osteogenic sarcoma (n=5), neuroepithelioma (n=1). All patients except one were given chemotherapy preoperatively and postoperatively and four received adjuvant radiotherapy. Tumor resection created a gap (n=8) or involved resection-arthrodesis (n=5, three knees, one ankle, one elbow). All reconstructions used a vascularized fibular flap with a complementary corticocancellous autograft for seven. RESULTS Complete carcinological resection was achieved in all cases. Mean follow-up was 50 months (range 12-144 months). There were no cases of local recurrence. Three patients presented lung metastasis; two patients died. Eleven of the twelve patients who underwent tumor resection involving the lower limb were able to walk with full weight bearing at 13.9 months (range 841 months), half of them without any supportive device. The MSTS score was 21/30 (range 7-29). Both ends healed for eleven of thirteen grafts. Outcome was good in four cases at 7.7 months (range 6-11), fair in seven (with 1-5 complementary procedures) at 14.8 months (range 10-45) and poor in two (nonunion at last follow-up). Among the fibular grafts which healed, primary healing of the distal end was noted in all cases, but not for the proximal end. Significant transplant hypertrophy was noted in 62% of patients, measured at mean 77.1% (range 25-128%). Complications were: skin necrosis (n=2), nonunion (n=4, three aseptic and one septic), disassembly (n=3 with two transplant fractures), and spontaneous fracture which healed (n=5, all but one treated orthopedically). There were four donor site complications: retraction of the hallux flexor (n=3), regressive paresia of the common fibular nerve (n=1). DISCUSSION The rate of healing in this series was similar to earlier reports. Healing was always achieved for the distal focus but not for the proximal focus which receives its blood supply from a branch of the anterior tibial artery which is not harvested. The defective blood supply can thus hinder bone healing. It is necessary to spare the proximal quarter of the fibula or harvest a bipediculated graft. The rate of graft hypertrophy was also similar, as was the rate of complications. The MSTS score was lower due to the poor results obtained with resection-arthrodesis of the knee joint. Graft fractures and aseptic nonunion are the most common complications but septic complications are more serious and can threaten graft survival. Complications at the donor site are exceptional. CONCLUSION Long bone reconstruction using an autologous vascularized fibular graft is a reliable technique providing satisfactory functional results. Complications can be prevented by making solid fixation and using a corticocancellous graft creating a favorable osteoinducing environment. A massive allograft is another solution providing good immediate mechanical stability.Resume La technique des greffons fibulaires vascularises fait partie de l’arsenal therapeutique des reconstructions des pertes de substance osseuse apres exerese tumorale. Nous rapportons notre experience concernant cette technique chez l’enfant apres resection carcinologique de tumeurs osseuses primitives malignes. Il s’agit d’une serie retrospective de 13 patients d’âge moyen 12 ans (4-17) comportant : 7 tumeurs d’Ewing, 5 osteosarcomes, un neuroepitheliome. Tous les patients (sauf un) ont beneficie d’une chimiotherapie pre et postoperatoire et 4 d’une radiotherapie adjuvante. Nous avons realise une reconstruction par fibula vascularisee a pedicule fibulaire, associee 7 fois a une autogreffe cortico-spongieuse, apres 8 resections intercalaires et 5 resection-arthrodeses. L’exerese carcinologique a toujours ete complete. Au recul de 50 mois (12-144), il n’y avait aucune recidive locale. Trois patients ont presente des metastases pulmonaires ; deux etaient decedes. Onze patients sur les douze operes au membre inferieur marchaient en plein appui a 13,9 mois (8-41) dont la moitie sans aucun appareillage. Le score MSTS etait de 21/30 (7-29). Onze transplants sur treize etaient solides aux deux extremites : 4 bons resultats a 7,7 mois (6-11), 7 moyens (une a 5 interventions supplementaires) a 14,8 mois (10-45) et 2 mauvais (non consolides). Tous les foyers fibulaires distaux ont consolide en premiere intention, a la difference des foyers proximaux. L’hypertrophie du transplant etait significative dans 62 % des cas, en moyenne 77,1 % (25-158). Les complications denombrees ont ete : 2 necroses cutanees, 4 pseudarthroses (3 aseptiques et une septique), 3 demontages (2 fractures du transplant) et 5 fractures spontanees, toutes traitees orthopediquement (sauf une) et ayant consolide. Quatre complications ont ete observees au site donneur : 3 retractions du flechisseur de l’hallux, une paresie regressive du nerf fibulaire commun.

151 Résultats des épiphysiodèses pour genu valgum de l’adolescent : vis versus agrafe : étude comparative

Introduction Dans le genu valgum de l’adolescent, l’epiphysiodese par agrafe de Blount est utilisee depuis plusieurs annees. Recemment, Metaizeau a decrit une technique par vis avec des premiers resultats satisfaisants. Cependant, il n’existe aucune serie comparative publiee. L’objectif de l’etude est de comparer les resultats de ces deux techniques au sein d’un meme service. Materiel Il s’agit d’une etude comparative monocentrique menee sur 40 adolescents presentant un genu valgum idiopathique. Le groupe 1 (20 patients) a ete opere par vis d’epiphysiodese ; le groupe 2 (20 patients) par agrafe. Les deux groupes sont comparables en terme de defaut d’axe des membres inferieurs. Methodes Les facteurs etudies sont : la correction clinique (ecart intermalleolaire (EIM)) et radiologique (axe anatomique femoro-tibal (AFT), axe anatomique femoral (AF)) du defaut d’axe, la douleur postoperatoire, les complications, la duree d’hospitalisation (ablation de materiel incluse), le delai de correction, la recuperation fonctionnelle et la rancon cicatricielle. Resultats Pour la correction, il n’existe pas de difference entre les deux groupes. L’EIM moyen passe de 12,5 a 1,3 cm dans le groupe 1 et de 11,2 a 1,9 cm dans le groupe 2. Pour le groupe 1, l’AFT moyen passe de 168,6° a 174,1° et l’AF moyen de 78,9° a 84,4°. Pour le groupe 2, l’AFT passe de 168,6° a 174,7° et l’AF de 78,4° a 84,4°. La duree moyenne de correction est de 10,5 mois dans le groupe 1 contre 11,9 mois dans le groupe 2. Les complications retrouvees dans le groupe 1 sont : douleur au niveau des vis (2 cas), reprise chirurgicale pour vis trop longue (1) ou trop courte (1), elargissement de la voie d’abord initiale pour l’ablation du materiel (1) ; dans le groupe 2 : douleur au niveau des agrafes (4), raideur articulaire materiel en place (2) expulsion d’agrafe (1), bris d’agrafe (1), elargissement de la voie d’abord initiale pour l’ablation du materiel (1). Dans chaque groupe un cas a necessite une epiphysiodese definitive laterale a cause d’une hypercorrection. Discussion Cette etude est la seule qui compare ces deux techniques. Elle confirme que l’epiphysiodese par vis est aussi fiable que l’epiphysiodese par agrafe. Ceci corrobore les resultats des series publiees. Conclusion L’epiphysiodese par vis est la technique a privilegier car les resultats sont identiques aux agrafes, le prejudice esthetique moindre et la recuperation postoperatoire plus rapide.

155 Nécroses avasculaires après échec du traitement orthopédique dans les luxations congénitales de hanche : intérêt du Salter complet, recul à 20 ans

Introduction Dans la luxation congenitale de hanche, le traitement orthopedique avant l’âge de 5 mois est en echec dans 5 % des cas et entraine une necrose de l’epiphyse femorale superieure dans 3 % des cas. Quand ces 2 facteurs « irreductibilite et necrose avasculaire » sont associes, le pronostic a long terme est pejoratif. Dans notre serie, nous comptons 12 cas de luxations congenitales compliquees de necroses avasculaires apres echec du traitement orthopedique. Nous avons traite ces patients par reduction chirurgicale et osteotomie innominee de Salter a l’âge de 18 mois. Nous presentons cette serie avec un recul de 20 ans. Materiels Entre 1979 et 1988, 12 enfants presentant une luxation congenitale de hanche (9 bilaterales et 3 unilaterales) ont ete traites orthopediquement. Parmi ces 21 luxations, 12 hanches se sont revelees irreductibles et sont compliquees d’une epiphysite. Devant l’irreductibilite et l’apparition de cette necrose, l’arret du traitement orthopedique a ete decide. Apres cette periode de « repos therapeutique », il a ete realise un Salter complet a l’âge de 18 mois. Les patients ont ete revus avec 20 ans de recul. Methodes Nous avons realise une analyse preoperatoire radiographique : evaluation du type de luxation selon Tonnis et du type de necrose en utilisant les classifications de Seringe et de Kalamchi. A 20 ans, nous nous sommes bases sur les criteres d’evaluation clinique de Mc Kay et les classifications radiographiques de Severin et de Stulberg. Resultats Les resultats cliniques sont excellents dans 8 cas et bons dans 4 cas. Sur le plan radiographique, on note selon la classification de Severin : 1 cas du groupe I, 7 groupe II, 4 groupe III, 0 groupe IV. Selon la classification de Stulberg, la repartition est globalement superposable : groupe I (1 cas), groupe II (9 cas) et un cas dans chaque groupe III et IV. Discussion L’etude montre que le Salter complet donne de meilleurs resultats que ceux attendus apres l’evaluation selon Seringe et Kalamchi. Cependant, l’interpretation de ces classifications reste difficile a l’âge de 18 mois. Conclusion En cas d’echec du traitement orthopedique et l’apparition d’une necrose avasculaire, nous recommandons une abstention therapeutique jusqu’a l’âge de 18 mois suivie d’une intervention de Salter complet.