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ABSTRACT: Surgical treatment of spinal deformities in infancy and early childhood (before age 6) is often very useful if the lesion is localized and curable by one unique surgery, such as hemivertebra resection and fusion. On the contrary, if the lesion, whether idiopathic or paralytic, is extended to a large part of the spine, early surgical treatment in infancy gives very disappointing results and often worsens the status of the child, especially respiratory function if the lesion is mainly thoracic. The goal of this paper is to explain in detail indications and management of non-surgical treatment of such lesions. These are variable according to localization, etiology, and associated anomalies, and are mainly based on proper casting (often repeated), bracing (often intermittent between casting) and proper respiratory equipment. From time to time, a surgical treatment is locally indicated, but most of the time results are disappointing and the best is to repeat non-surgical treatment until proper definitive arthrodesis can be performed. This approach is not very rewarding for the child and family, but is clearly better than sudden extensive surgery in early childhood with very severe and disastrous results in adulthood. It is our hope that the recommendations and thoughts presented in this paper will help readers to manage young children using the most efficient, non-aggressive, but long-lasting therapy.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 03/2006; 92(1):73-82. · 0.37 Impact Factor
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ABSTRACT: The original description of the paraspinal posterior approach to the lumbar spine was for spinal fusion, especially regarding lumbosacral spondylolisthesis treatment. In spite of the technical details described by Wiltse, exact location of the area where the sacrospinalis muscle has to be split remains somewhat unclear. The goal of this study was to provide topographic landmarks to facilitate this surgical approach. Thirty cadavers were dissected in order to precisely describe the anatomy of the trans-muscular paraspinal approach. The level of the natural cleavage plane between the multifidus and the longissimus part of the sacrospinalis muscle was noted and measurements were done between this level and the midline at the level of the spinous process of L4. A natural cleavage plane between the multifidus and the longissimus part of the sacrospinalis muscle was present in all cases. There was a fibrous separation between the two muscular parts in 55 out of 60 cases. The mean distance between the level of the cleavage plane and the midline was 4 cm (2.4-5.5 cm). In all cases, small arteries and veins were present, precisely at the level of the cleavage plane. We found it possible to easily localize the anatomical cleavage plane between the multifidus part and the longissimus part of the sacrospinalis muscle. First the superficial muscular fascia is opened near the midline, exposing the posterior aspect of the sacrospinalis muscle. Then, the location of the muscular cleft can be found by identifying the perforating vessels leaving the anatomical inter-muscular space.
European Spine Journal 06/2005; 14(4):366-71. · 1.97 Impact Factor
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ABSTRACT: This retrospective analysis involved a continuous series of twenty cases of lumbosacral spondylolisthesis with major displacement treated before maturity. We compared our experience using a non-instrumented lumbosacral fusion technique with the results of other techniques proposed in the literature.
We reviewed the cases of twenty children and adolescents who underwent surgery in our unit. For each case, we recorded the clinical history and course to last follow-up. X-rays were studied and manual measurements taken of the different parameters used to analyze the spine. Data were recorded in a database for statistical analysis. Sixteen of the twenty cases showed spinal deformation causing lumbalgia, generally associated with radiculalgia. Mean age at surgical treatment was 13 years 3 months, range 7 years 2 months to 17 years 6 months. All of the children has Meyerding stage 3 or 4 displacement associated with lumbosacral kyphosis. Surgical treatment followed a period of progressive reduction by traction and suspension in lordosis using a hammock. All twenty patients underwent posterolateral arthordesis using a cancellous graft between L4 and the sacrum. The fusion was performed after fashioning a thoraco-lumbo-pelvic cast including both thighs in the position of reduction. A complementary time for anterior arthodesis was needed for eight patients.
The postoperative period was uneventful in twelve patients. Two children developed intestinal obstruction with a peritoneal bridle. Three children had an L5 radicular deficit and three sphincter disorders. All neurological disorders resolved in a few months. At mean postoperative follow-up of 5 years 3 months, the arthrodesis appeared to be fused in 19/20 cases. Only one patient presented a lucent line in the zone of the bone graft suggesting possible fibrous nonunion. Eighteen patients were symptom free and led a normal life. Two patients complained of moderately bothersome lower back pain.
Many of the children in our series had major lumbosacral dysplasia with a verticalized sacrum, aggravating the lumbosacral kyphosis. This led to an increased pelvic tilt and decreased sacral slope. Progressive preoperative reduction of the lumbosacral kyphosis allowed conducting the lumbosacral fusion under favorable conditions. We did not open the spinal canal and avoided the mid line in order to protect as much as possible posterior spinal stability and preserve all the bone surfaces receiving the posterolateral graft. We reserved indications for complementary anterior lumbosacral arthrodesis to the most exaggerated cases of lumbosacral kyphosis. The therapeutic program is long due to the progressive preoperative reduction and the strict period of immobilization after surgery. In our experience, this approach allows quality lumbosacral fusion with good correction of the lumbosacral kyphosis. Neurological complications remain frequent and can occur during even slow progressive reduction.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 03/2005; 91(1):5-14. · 0.37 Impact Factor
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ABSTRACT: Secondary adaptive bone changes and joint distorsions in clubfoot may present a barrier to adequate correction of the deformity. The purpose of our study is to show how the lateral excision of the calcaneus distal part as described by Lichtblau, in combination with an appropriate medial release allows better correction of forefoot deformity, with less recurrence rate.
Between 1974 and 1982, 43 feet in 38 patients underwent this type of surgery. Lateral excision o the calcaneus was decided preoperatively in 34 feet, for recurrence of the forefoot deformity following previous surgery. In the remaining 9 feet, this lateral excision was decided intraoperatively, because of an uncomplete correction of the fore part of the foot, despite an adequate posteromedial release. The resected angle from the distal intra-articular part of the calcaneus varied from 10 to 30 degrees with an average of 15 degrees.
All our results were evaluated at end of growth. Mean age at follow-up was 15 years and 4 months, with an average period of 10 years and 7 months following surgery. The average forefoot adduction moved from 21 degrees preoperatively to 1 degree at last follow-up. The clinical calcaneocuboid mobility was preserved in 37 cases. Four types of complications were encountered in 7 patients: pain in 5 cases, calcaneocuboid fusion in 6 cases, recurrence of deformity in 2 cases, and overcorrection in 5 cases; this last complication was related to intraoperative overcorrection rather than a progressive deterioration of the result, and had no clinical significance. No overcorrection was seen after calcaneocuboid fusion. We have found no relation between age at surgery, and the incidence of calcaneocuboid fusion, but the two cases operated on children under one year old, ended up with a bad result.
The resection of a single side of a joint may permit normal joint function to be retained. The resected cartilage is replaced by a fibrocartilage that resembles the original articular cartilage, provided the resected defect is deep enough to allow vascularization from the underlying bone.
The success of this method depends on an accurate surgical technique, as described by its promoter. It can be of great help in severe and complicated clubfeet. It achieves the goal with a calcaneocuboid function often preserved.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 02/1995; 81(8):709-15. · 0.37 Impact Factor
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ABSTRACT: Risks and benefits of using a tibial graft for posterior spinal fusion in neuromuscular scoliosis were evaluated in a long-term follow-up study. A consecutive series of 72 patients underwent posterior spinal fusion for neuromuscular scoliosis.
Radiologic outcome was assessed to evaluate the quality of the spinal fusion. Patients were followed serially to detect donor site complications. Mean follow-up was 17 years and 8 months (minimum: 6 years, 6 months).
Mean age of the patients at the time of surgery was 15 years. Progression of the curvature was minimal at last follow-up (mean progression at last follow-up: lumbar curve, 4.5 degrees; thoracic curve, 5.3 degrees). Concerning donor site complications, four patients had a leg length discrepancy of less than 2 cm at last follow-up. This complication was related to tibial overgrowth at the donor site.
Solid fusion was defined in this long-term study as the absence of modification of the radiologic aspect at last follow-up in addition to the presence of a massive contagious trabecular fusion mass.
The fusion appeared to be solid in all patients. No obvious pseudarthrosis could be documented. The constant successful outcome differs significantly from spinal fusion that uses bank bone. The absence of stress fracture was correlated to the low level of constraint in this essentially nonambulatory population.
This experience indicates that the tibial graft deserves consideration in posterior spinal fusion for neuromuscular scoliosis.
Spine 08/1994; 19(14):1628-31. · 2.08 Impact Factor
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ABSTRACT: The authors studied 54 lesions, caused by histiocytosis X, that affected the spines of 28 children. The clinical, radiologic, biologic, and therapeutic aspects are described. The orthopaedic surgeon has a role to play in confirming the diagnosis, treating the lesion, and in following up.
Spine 03/1987; 12(2):167-72. · 2.08 Impact Factor
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Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 02/1987; 73 Suppl 2:164-7. · 0.37 Impact Factor
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Annales de Chirurgie 07/1986; 40(5):287-93. · 0.35 Impact Factor
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Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 02/1986; 72 Suppl 2:63-5. · 0.37 Impact Factor
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ABSTRACT: The authors have performed 34 Dwyer's calcaneal osteotomies in children with pes cavus confined to the medial arch in non-paralytic lesions (poliomyelitis and spina bifida were excluded). In 12 cases it was associated with osteotomy of the 1st metatarsal or with plantar release. No arthrodeses were performed in these 34 cases. After an average follow-up of five years the results were doubtful: in 24 instances the deformity was the same or worse. In 21 cases a secondary operation was necessary. The authors considered that the Dwyer's procedure corrects only the varus of the heel which is a secondary deformity. They believe that, in pes cavus, there is a dynamic clawing of the toes in the swing phase of gait. This produces secondary deformities. In the sagittal plane there is a synergic or paralytic imbalance at the metatarso-phalangeal level leading to vertical displacement of the 1st metatarsal and deepening of the medial arch. In the frontal plane, this vertical displacement leads to an irreducible pronation of the forefoot with secondary varus of the heel. In the horizontal plane a lateral rotation of the talus results in varus of the calcaneum.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 02/1985; 71(8):563-73. · 0.37 Impact Factor
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ABSTRACT: We report a new therapeutic approach for bladder exstrophy and epispadias in one case of failed epispadias repair. The width of the pelvis was measured by what we defined as the anteroposterior diameter (APD) on combined transverse computed tomography (CT) scan cuts of the pelvis. The APD was half the normal value in an incontinent patient with failed epispadias repair. He underwent a supraacetabular osteotomy of the pelvis with progressive anterior distraction of the anterior segment of the pelvic ring. Four months later, hardware was removed, and the APD was near normal value. Within 9 months of follow-up, the patient was dry day and night. We believe that in patients with failed exstrophy and epispadias repair, APD seems to be a predictive criterion for continence, and results of the reconstructive surgery with osteotomy should be improved by distraction of the anterior segment of the pelvic ring.
Journal of Pediatric Orthopaedics 19(4):536-9. · 1.16 Impact Factor
