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ABSTRACT: Long bone lengthening surgery using progressive surgical methods has been the source of frequent complications. Some authors have classified these complications either descriptively, according to the date of onset after the operation, or based on their severity. The Caton classification (1985) has had the virtue of contributing the notion of the treatment contract stipulating the objective to reach in treatment. Within the context of the preoperative information delivered to patients and their family, this contract can be improved by adding a notion of maximum treatment duration. The objective of this study was therefore to propose a classification that includes honoring a triple contract associating the planned gain in bone length, the duration of treatment, and the occurrence of sequelae.
The classification of complications proposed includes four grades: grade I: triple contract honored, including a few treatments without general anesthesia; grade II: triple contract fulfilled, but with unplanned interventions under general anesthesia; grade III: the time stipulated was not honored because the time to obtain bone union was too long or because the program was interrupted; grade IV: sequelae are present. This classification was assessed based on a consecutive series of 34 surgical procedures in 32 patients (two patients underwent two lengthening procedures during this period) at 43 bone segments associating progressive lengthening with external fixation or with nail lengthening. The grade of each complication was determined by each of the authors according to the classification proposed and other classifications reported in the literature (Caton, Paley, Popkov, and Donnan).
Approximately one-third (10) of the 34 lengthening procedures did not present any complications. Two-thirds (24) presented 30 complications. Consensus was obtained between all the authors on the grades proposed for our classification and the Caton classification, but consensus was not reached with the other classifications in which part of the interpretation was subjective (Paley, Popkov, and Donnan).
The classification proposed required respecting predetermined objectives during limb lengthening surgery based on a triple contract: gain, duration, and function. It is reliable and reproducible by different operators because the criteria are objective. It can also be applied to diverse surgical techniques, whether with external fixation and/or internal osteosynthesis.
Level IV: retrospective study or historical series.
Orthopaedics & Traumatology Surgery & Research 09/2012; 98(6):629-37. · 0.94 Impact Factor
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ABSTRACT: Diaphyseal and metaphyseal fractures in children are frequently treated with the flexible intramedullary nailing (FIN) method. The aim of this study was to record postoperative complications and outcome in consecutive fracture patients treated with the new precurved tip and shaft nails and dedicated ergonomic instrumentation.
We report the analysis of 100 consecutive fractures followed up for a minimum of 6 months. Ninety-seven children were included, comprising 77 shaft and 23 metaphyseal fractures. Demographic data, duration of surgery, nail and medullary canal diameter, date of nail removal, clinical assessment, follow-up radiographs and all complications were recorded.
Mean age was 9.7 years, and mean body weight 35.1 kg. Twenty-one fractures had associated lesions. Mean duration of surgery was 42.4 minutes. Nail removal was at a mean 6.1 months. Twelve percent of patients had complications, with six insufficient reductions, one delayed union, one non-union, one iterative fracture, and three skin impingements. Unexpected surgical revision was required in seven cases. At follow-up, only one patient showed functional impairment, with 20° pronation loss, and three showed more than 10° axial deviation on X-ray.
The low rate of skin impingement compared with the literature may be due to the new dedicated instruments. We believe that other complications can be avoided if one follows the FIN principles, avoiding weak assembly due to an insufficient nail/medullary canal diameter ratio, which is a limiting factor for indications in adolescents. The surgeons reported that precurved shaft nails facilitated the FIN procedure, although this subjective judgment may be due simply to the novelty of the nails.
Level IV. Retrospective study.
Orthopaedics & Traumatology Surgery & Research 05/2012; 98(4):369-75. · 0.94 Impact Factor
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ABSTRACT: Most of the techniques for forearm lengthening involve external fixation to achieve stability and provide progressive distraction. We introduce the use of elastic stable intramedullar nailing (ESIN) in combination with external circular assembly for the procedure. The purpose of this prospective study was to compare Ilizarov's classical technique with this combined technique.
Fifty-seven patients, with forearm length discrepancies or deformities either congenital or acquired, were prospectively followed-up. Patients were divided in two groups: 35 had only external fixation, and 22 had external fixation-ESIN combined techniques. Patients were assessed for clinical and radiographic outcome with a mean follow-up of 21 months after external device removal.
Overall lengthening was 45.0mm. Healing index (HI) was 22.2d/cm with the combined technique, and 32.0 d/cm with external fixation. HI was 30% better when ESIN was used, for congenital and for overall cases. Combined technique has a lower complication rate.
Although forearm lengthening still remains a time-consuming procedure, ESIN can shorten external fixator wearing time. No additional complication occurred and bony complications seem to be limited by the nails. We recommend this technique, which we now use for most of our patients undergoing limb lengthening.
Level IV.
Orthopaedics & Traumatology Surgery & Research 05/2012; 98(4):376-82. · 0.94 Impact Factor
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ABSTRACT: Partial closure of the growth plate is an uncommon complication in the distal radius even though distal radial fractures are among the most common injuries in children. We report two cases of resection of a bony bridge in the distal radial growth plate in boys aged 8 and 9 years with a description of the operative technique.
The Journal of hand surgery, European volume. 06/2011; 37(2):170-5.
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ABSTRACT: This retrospective series evaluated the surgical treatment of hip arthritis in children by needle aspiration-irrigation alone.
Forty-three cases of septic hip arthritis were treated by needle aspiration-irrigation under general anesthesia associated with intravenous then oral administration of antibiotics. Clinical and biological criteria at admission, during hospitalization and at final follow-up were studied to identify any criteria carrying a predictive value for unsuccessful needle aspiration-irrigation.
Thirty-eight hips had a favorable outcome in this series, while secondary open arthrotomy was required in five hips for further irrigation. Common criteria found in the group requiring open arthrotomy were a diagnosis delay of at least 6 days between initial clinical symptoms and treatment as well as markedly abnormal biological results at admission. A threshold for the predictive value of certain variables was identified including C-reactive protein above 100, white polynuclear blood count above 15000, and sedimentation rate above 25 in the first hour and 50 in the second hour.
Treatment modalities for septic arthritis of the hip remain controversial in children and various techniques have been shown to be effective in the literature. Needle aspiration-drainage, the least invasive of these, has been shown to have good results, even in the hip, even though this is a deep, tight, joint which is known to be difficult to drain. Prognostic criteria are difficult to identify, however all authors agree that delayed treatment makes evacuation of intra-articular debris especially difficult.
Needle aspiration-irrigation is effective in septic arthritis of the hip, as long as basic principles are followed. Delayed treatment and certain biological criteria should be taken into account when selecting a treatment, since negative predictive criteria identified in this series were present in the five hips requiring secondary arthrotomy.
Orthopaedics & Traumatology Surgery & Research 03/2011; 97(3):308-13. · 0.94 Impact Factor
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ABSTRACT: In case of hindfoot pain, diagnosis of calcaneonavicular tarsal coalition may be missed on X-ray due to the absence of any visible synostosis. All other possible etiologies (too-long anterior process (TLAP) of the calcaneum, synchondrosis, syndesmosis) must be investigated. The literature tends to recommend imaging associating standard X-ray and CT, and possibly bone scintigraphy. MRI is, however, also worth assessing, due to the many non-osseous forms calcaneonavicular pain may take.
Thirty-two cases of surgically treated calcaneonavicular tarsal coalition were studied. Nineteen cases, in 14 children, over a 10-year period, showed no visible synostosis on initial standard X-ray. In seven cases, bone scintigraphy was performed, CT in seven and MRI in 12. On the basis of the literature, our attitude was in favor of X-ray associated to CT in our early experience. Repeated diagnostic difficulties, however, led us to replace CT by MRI in case of foot pain combined to symptomatology suggestive of coalition.
The series comprised four cartilaginous forms, four fibrous forms and eight TLAPs. In 10 of the 19 feet, radiology was strictly normal, the others showing indirect osseous signs. Only three of the seven scintigraphies showed hyperfixation. CT-scan enabled diagnosis in seven cases (two synchondroses and five rudimentary forms), and missed diagnosis in four (two cartilaginous and two fibrous forms). Second intention MRI showed two synchondroses and two syndesmoses. In the light of these 11 cases, a subsequent series of eight feet was assessed by MRI in first intention, obtaining systematic diagnosis. In all the feet of the series, the symptomatic coalition was treated by surgery, allowing peroperative findings to be compared with the imaging data.
Given a rigid and painful foot syndrome suggestive of tarsal coalition, two diagnostic situations arise: (a) the clinical aspect is suggestive and standard X-ray enables diagnosis; (b) the clinical aspect is suggestive, but radiography proves non-contributive, in which case we recommend MRI with sagittal, frontal and axial slices in gadolinium-enhanced T1-weighted and fat-sat T2-weighted sequences, revealing direct (cartilaginous or fibrous coalition) or indirect signs (peripheral inflammation, osteomedullary edema, chondral lesion) unobtainable on CT scans. MRI is particularly effective in as much as most of the children concerned will not have reached bone maturity.
We consider MRI to be the most effective means of precise diagnosis (causes and consequences) of tarsal coalition, especially for calcaneonavicular locations. It entails minimal invasion and irradiation, at a lower cost than CT associated to scintigraphy.
IV. Diagnostic study.
Orthopaedics & Traumatology Surgery & Research 01/2011; 97(1):67-72. · 0.94 Impact Factor
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ABSTRACT: Bone tumours are frequent conditions in children, and their surgical resection may lead to extensive defects which reconstruction is often challenging. Indeed, local conditions do not promote bone healing, and the achieved surgical result requires to be life-lasting. Capanna suggested a reconstruction technique combining massive allograft and free vascularized fibular flap. The first one is intended to withstand mechanical stress, and the second one offers biological and vascular support to improve bone healing and prevent infections.
We report our experience with this technique when applied to the lower limb in a prospective study including seven children, with a mean follow-up of 44 months.
Bone healing was achieved by one single procedure in 85.7% of the cases, usually 7 months after surgery. Six out of seven patients achieved a final and long-lasting outcome, five of them following a simple surgical history. Partial weight-bearing was post-operatively allowed at about 2 months, full weight-bearing was initiated at about 5.5 months.
A low complication rate was reported despite the extent of the disease and the type of the surgical procedure. Capanna's combined reconstructive technique appears very efficient in the management of massive bone defects following tumour resection in children's lower limb.
Level IV. Retrospective therapeutic study.
Orthopaedics & Traumatology Surgery & Research 06/2010; 96(4):340-7. · 0.94 Impact Factor
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ABSTRACT: During progressive lower limb lengthening in the management of Ollier's disease, the mean bone-healing index usually reported in the literature stands around 35 days/cm. One of the therapeutic objectives is to reduce the duration of the external fixation.
The use of an elastic stable intramedullary nailing system (ESIN) combined with a circular external fixator significantly reduces the healing index.
Two groups of patients were compared. In group I, seven patients were operated on for progressive limb lengthening using a circular external fixator associated with an ESIN system: four monosegmental femoral lengthenings, one monosegmental tibial lengthening and two polysegmental femorotibial lengthenings. Nailing was performed via two intramedullary nails already used in traumatology. The date of external fixator removal coincided with that of radiographic healing. The nails were left in place. Group II included 37 patients who underwent limb lengthening by means of an external fixator only. The healing index was calculated and complications were analysed in both groups.
The mean healing index (HI) values were: in group I: 23.3 days/cm for the femur, 22.4 days/cm for the tibia and 11.6 days/cm for polysegmental lengthenings ; in group II: 31.6 days/cm for the femur, 35.7 days/cm for the tibia and 19.9 days/cm for polysegmental lengthenings. Group I demonstrated a statistically significant decrease in the HI for monosegmental femoral lengthenings.
A substantially reduced duration of external fixation, limited postoperative complications and prevention of later pathologic fractures are the reported advantages of the associated use of a circular external fixator with an ESIN system in the management of Ollier's disease.
Level III, comparative retrospective study.
Orthopaedics & Traumatology Surgery & Research 06/2010; 96(4):348-53. · 0.94 Impact Factor
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ABSTRACT: Detachment of the proximal epiphyseal plate of the femur is a rare observation in infants. The context usually involves obstetrical injury or child abuse. There is however a high risk in certain children with epilepsy. Fractures and dislocations can occur during hypertonic seizures in a context of iatrogenic bone weakening due to drug treatments. Emergency reduction is required and requires a double fixation with osteosynthesis and plaster cast in order to reduce the risk of secondary displacement in this particular context. The risk of major impact on growth requires prolonged radiographic and clinical follow-up.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 07/2008; 94(4):403-6. · 0.37 Impact Factor
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ABSTRACT: Idiopathic scoliosis (IS) is correlated with a muscular disequilibrium of the spine and an alteration of balance control, efficient performance of the latter being necessary for physical and sporting activities (PSA). However, the type of the IS curve has different effects on muscle and on balance control according to the primary curve location. This study aimed to determine the relationships between IS type and PSA practice. One hundred and sixty-nine girl adolescents with IS [double major curve (DMC) scoliosis: n=74; single major curve (SMC) scoliosis: n=95] and 100 age-matched control girl adolescents completed an epidemiological questionnaire informing on curricular and extracurricular PSA. Adolescents with DMC scoliosis practised more PSA than those with SMC scoliosis. Moreover, among all PSA referenced, gymnastic activities are the most practiced PSA both in IS teenagers, whatever the curve type, and in controls. Besides, teenagers practising gymnastics were more numerous in those with DMC scoliosis than those with SMC scoliosis and controls. The highest proportion of adolescents with DMC scoliosis practising PSA, especially gymnastics, could be linked to the fact that they are less subject to scoliosis-related biomechanical repercussions leading to a better balance control, which is essential in these PSA.
Scandinavian Journal of Medicine and Science in Sports 03/2008; 18(6):751-5. · 2.87 Impact Factor
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Revue médicale suisse 11/2007; 3(127):2232-7.
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ABSTRACT: Fractures of the distal extremity of the tibia include physeal injuries among teenagers and more complex fractures among adults. Displacement causes the compression of the muscles located between the distal tibia and the superior extensor retinaculum (SER). Among the muscles of anterior compartment of the leg, the extensor hallucis longus (EHL) is particularly vulnerable due to the amount of muscle fibers extending under the SER. Consequently, a partial anterior compartment syndrome could result, affecting only the distal portion located under the SER. In clinical practice, Mubarak measured the intramuscular pressure isolated under the SER and suggested the physio-pathological hypothesis of a compression of distal muscle fibers. The aim of this study is to compare the ratios of anterior compartment muscle fibers extending under the SER. Twenty legs were dissected in order to study how much of these muscles extend under the SER, their passages possibly dividing into two of the SER, as well as their vascularization and their innervation. On the last seven legs, the engagement of the muscles were measured in the spontaneous position and with a dorsal flexion of 0 degrees . The posterior muscle fibers of this compartment always descend lower than the anterior fibers. EHL muscle fibers and those of the inconsistent fibularis tertius always extend under the retinaculum, unlike those of the tibialis anterior and of the extensor digitorum longus. The EHL muscle extends under the SER more than the other muscles. Its posterior fibers are longer when this muscle goes through a dividing into two of the retinaculum. Its vascularization seems lesser, which could explain why this muscle tends to suffer more. The deep fibular nerve innervates the anterior compartment of the leg, yet no nerve branches can be found under the upper edge of the retinaculum. In all cases, the muscle fibers do not extend as much under the SER in a 0 degrees of dorsal flexion. This anatomical study allows us to explain why the EHL is more likely to suffer from this partial compartment syndrome and confirms that when the latter occurs it is necessary, in all cases, to do emergency surgery opening the distal crural fascia and necessarily including the SER.
Surgical and Radiologic Anatomy 07/2007; 29(4):303-11. · 1.06 Impact Factor
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Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 11/2006; 92(6):615-22. · 0.37 Impact Factor
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ABSTRACT: The influence of physical and sporting activities (PSA) on idiopathic scoliosis (IS) is still obscure. The aim of this study was to investigate whether such an influence exists and if so, to determine its characteristics. Two hundred and one teenagers with IS and a control group of 192 adolescents completed an epidemiological questionnaire. Those practising gymnastics were more numerous in the IS group than in the control group. Moreover, the practice of gymnastics was chosen before IS was diagnosed. As gymnastic activities are considered neither as a therapy nor as a precursor of IS, the distribution observed could be linked to a common factor that both increases the likelihood of IS and favors the practice of gymnastics. Joint laxity (JL) may be such a common factor, and was therefore tested (wrist and middle finger) on 42 girls with IS and 21 girls of a control group. IS patients, practising gymnastics or not, showed a higher JL than the control group practising gymnastics or not. Furthermore, the groups practising gymnastic activities did not show higher JL levels than the other groups. Children with a high JL could be drawn toward gymnastics because of their ability to adapt to the constraints of this sport. Girls with a high JL may therefore be prone to developing IS. The fact that most teenagers with IS practise gymnastics could be related to a higher JL.
Scandinavian Journal of Medicine and Science in Sports 09/2006; 16(4):231-6. · 2.87 Impact Factor
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Archives de Pédiatrie 07/2006; 13(6):545-8. · 0.30 Impact Factor
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ABSTRACT: The malignant bone tumours in children are rare, concerning 5% of the all paediatric tumours. Among all paediatric bone tumours, 15% of them are malignant. The main bone tumours in children are the osteosarcoma and the Ewing sarcoma. The diagnosis and treatment need a multidisciplinary medical team. It is essential in front of potential clinical or radiological signs, to perform quickly the specific medical exams and biopsy. The treatment needs a paediatric medical and surgical staff.
Annales Françaises d Anesthésie et de Réanimation 05/2006; 25(4):432-9. · 0.84 Impact Factor
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ABSTRACT: Bone lengthening with the Ilizarov technique gives good results but certain disadvantages are common: possible axial deviation during lengthening, long time to bone union, risk of fracture after removal of the external fixator. Associating the Ilizarov technique with elastic stable intramedullary nailing (ESIN) commonly used in traumatology has to be evaluated. We conducted an experimental study and report results of the first clinical application.
Eleven lengthenings of the tibia were conducted in dogs aged 1 to 4 years using an Ilizarov external fixator associated with ESIN. Lengthening started on day 1 and continued for 28 days. X-rays were obtained every week during lengthening, then at 15 and 30 days during the fixation period and 30 days after removal of the fixator. In two cases, arteriography was performed. In a pilot clinical trial, fourteen patients (8 males, 6 females) were treated with this method (1 humerus, 1 forearm, 7 femurs, 5 tibias). Mean patient age was 14 years.
In the experimental study, the x-rays showed rapid ossification of the regenerate which led to increased tibia length in 7 cases from 1.25 to 2 mm/day. Total bone union was observed in four dogs during the lengthening period. At day 15 of the fixation period, all tibia had fused with a good quality cortical bone and healing of the growth part of the regenerate. In three dogs, the external fixator was removed at day 15 of fixation and weight-bearing was total with the ESIN in place. No axial deviation and no skin problems were observed. The medullary artery was seen on the two arteriograms. In the clinical trial, bone union of the regenerate appeared earlier than in the Ilizarov series. The regenerate always displayed good density on the x-rays, proving intense bone activity. In three patients, the lengthening rate was increased to avoid premature bone fusion. The endosteal bone regenerate was obvious. Mean healing index was 18.6 days/cm (SD=6.2). Weight-bearing was allowed at six weeks. The desired correction was achieved in all patients and no complications were related to ESIN.
Bone lengthening may be obtained with an intramedullary locking nail which avoids the use of an external fixator but also destroys the endomedullary circulation. Our experimental and clinical study shows that use of an ESIN does not inhibit the endosteal regenerate and seems to improve new bone formation. In many patients, the lengthening rate had to be increased to avoid premature bone fusion. When used in optimal conditions, ESIN can stimulate new endosteal and periosteal bone formation. In addition, ESIN increases shaft stability avoiding the risk of axial deviation. ESIN plays an additional role of stabilization after early removal of the external fixation.
Revue de Chirurgie Orthopédique et Réparatrice de l Appareil Moteur 10/2004; 90(5):399-410. · 0.37 Impact Factor
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ABSTRACT: To assess the effect of internal foot progression angle (inturning) on knee dynamics in children with treated clubfeet.
Prospective study dividing a population of clubfeet according to the factor inturning.
Excessive internal or external foot progression angle increases knee flexion by a backward shift of the ground reaction force to the knee joint in children with cerebral palsy. Similarly, inturning in clubfeet was hypothesized to shift the ground reaction force backwards with reference to the knee joint, increasing the external knee flexion moment and the maximal knee flexion at stance.
Three-dimensional gait analysis was performed on 20 children with surgically treated clubfeet (n=28) to assess alterations of knee dynamics related to inturning (>7 degrees ) and on 13 normal children.
Inturning occurred in 46% of the clubfeet and was associated during stance, at maximal knee flexion, to an increase in maximal knee flexion (+7 degrees ), external knee flexion moment (+60%) and related lever arm to the knee (+100%) and at minimal knee flexion, to a reduction in external knee extension moment (-62%) and related lever arm (-58%). Inturning was associated with a more frequent prolongation of internal knee extension moment and of rectus femoris activity exceeding 50% of stance.
Inturning in clubfeet is associated with knee dynamics alteration, which might contribute to the long-term development of knee osteoarthritis.
The therapeutic correction of inturning in clubfeet would be of importance if the consecutive knee dynamics alteration is shown by further studies to contribute to long-term degenerative knee pathology.
Clinical Biomechanics 08/2003; 18(7):670-6. · 2.07 Impact Factor
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Archives de Pédiatrie 06/2003; 10 Suppl 1:177s-180s. · 0.30 Impact Factor
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ABSTRACT: Eight children developed osteochondroma (OS) at a mean of 88 months after hematopoietic stem cell transplantation (HSCT). The mean age at HSCT was 56 months (12-84). This represents a cumulative incidence of 20% among patients less than 18 years of age transplanted from 1981 to 1997. These eight patients underwent allogeneic (n = 2) or autologous (n = 6) transplantation for either acute leukemia (n = 6) or neuroblastoma (n = 2) after a conditioning regimen including TBI (n = 7) or a combination of Bu and CY. OS was multiple in seven patients and solitary in one. Eight lesions were resected and all were benign. Four children received growth hormone before diagnosis of OS, but there was no clinical, radiological or histological difference between those who did not. Univariate analysis showed an increased rate associated only with autologous HSCT, with a 31.7% probability of a new OS at 12 years after HSCT. Osteochondroma should be added to the other adverse effects of HSCT in children.
Bone Marrow Transplantation 05/2002; 29(7):611-4. · 3.75 Impact Factor
