[Treatment of the motor cerebral palsy child with botulinum toxin A: mode of action, injection places in management]

Many studies have demonstrated the effectiveness of botulinum toxin injections in order to decrease spasticity in cerebral palsy. However it is essential to carefully assess children to be treated, and the muscles which need to be injected. Injections of soleus in dynamic equinus without fixed contrature in very young children provide the best results, but other muscles may be injected such as upper limbs muscles. Injections have mainly a functional purpose, but sometimes they may contribute to prevent fixed contractures or pain during nursing.

[Total hip arthroplasty without cement in children and adolescents: 17 cases]

PURPOSE OF THE STUDY

Hip disease can produce major pain and functional disorders in children who should benefit from total hip arthroplasty. We report our experience with total hip prostheses implanted without cement in children.

MATERIAL AND METHODS

We performed 17 total hip arthroplasties in 13 children who had various conditions, mainly chronic juvenile osteoarthritis and aseptic osteonecrosis secondary to sickle cell anemia. The acetabular inserts were not cemented. All the femoral stems were custom-made using computer-assisted preoperative planning based on standard x-rays and computed tomography findings. Outcome was assessed on the basis of patient satisfaction, pain, and function. Radiographically, we assessed stem implantation, stability and integration. Results were classed with the Harris score and also with the Steinbrocker classification in order to take into account the child's overall functional handicap.

RESULTS

Mean follow-up was 36.4 months. There were three cases of superficial hematoma, one case of superficial sepsis and one acetabular loosening. All patients were satisfied. Unsatisfactory function, observed in 80% of the children preoperatively, was found in only 17% postoperatively. The Harris score improved from 23.8 preoperatively to 87.7 at last follow-up. There were no cases of stem loosening and integration was achieved in 85.3% of the cases proximally in the area with hydroxyapatite surfacing.

DISCUSSION

The problem with these children is to determine when total hip arthroplasty should be proposed. We retain three important indications: uncontrollable chronic pain, normal school attendance impossible, no other possibility for conservative surgery. Several studies have reported only mediocre results with cemented stems. We opted for custom-made stems without cement for three reasons: preservation of bone stock, better adaptation to bone whose quality and morphology had been remodeled by the underlying condition and repeated osteotomies which also affect the gluteus medius, and finally, better chance of success for future revisions in these active young patients.

CONCLUSION

The question on whether or not total hip arthroplasty should be performed early in these children to avoid osteotomies which could alter the longevity of a future prosthesis remains open. Custom-made stems inserted without cement have provided satisfactory results in our experience. To date, follow-up is too short to compare our results with those obtained by others using cemented stems.

[Biphosphonates in children: present and future]

Biphosphonates are synthetic analogs of the natural pyrophosphate molecule, introduced primarily for the treatment of Paget disease of bone. Their main mechanism of action consisting in an inhibition of osteoclastic activity is critical for treatment of disorders including an increased bone resorption. In childhood osteoporosis (especially osteogenesis imperfecta), hypercalcemia and heterotopic calcifications are the three main situations in which they have been successfully used, with however few follow-up and no controlled studies. The evolution of these compounds generating more potent products, given orally, with limited effect on bone mineralization should allow an extension of their use in pediatric patients. Multicentric studies are now necessary to specify their efficacy and guidelines for use in children.

[Progressive forearm lengthening in children: 14 cases]

PURPOSE OF THE STUDY

There are few indications for forearm lengthening in children. Several techniques have been proposed. We report our experience with progressive lengthening of the forearm in children using a unilateral axial external fixator and an improved technique consisting in initial insertion of an intramedullary guide wire.

MATERIAL AND METHODS

Since 1990, we performed 14 forearm lengthenings in 9 children. Radial agenesia (5 forearms in 4 children), and hereditary multiple exostosis (3 forearms in 2 children) were the predominant causes. The ulna was involved in 9 cases and the radius in 5. Age at initiation of the lengthening procedure ranged from 4.5 to 14.8 years (mean 9.9). The lengthening technique consisted in a transverse subperiosteal osteotomy of the bone shaft then progressive distraction with a unilateral axial external fixator. When axial deviation had to be corrected, we used a subtraction osteotomy. In our last 10 cases, we inserted an intramedullary guide wire in the lengthened bone. The external fixation was left in place throughout the lengthening procedure and until complete bone healing. Serial radiographs were used to assess bone healing, the degree of lengthening achieved and any axial deviation at the end of lengthening.

RESULTS

All 14 forearms were reviewed at a mean 50.6 months. Mean lengthening was 26.4 mm (range 10 - 52 mm). There were no nerve or vessel complications. In one case, reducible claw finger completely regressed after temporary interruption of the lengthening. There were 6 cases of late healing requiring a secondary bone graft. The healing index was 61.9 days per cm gained length. There were 3 cases with an axial deviation at the end of lengthening.

DISCUSSION

Insertion of a guide wire in the bone being lengthened reduced the risk of late healing compared with lengthening procedures without a guide wire, avoiding axial deviation. In addition, this technique led to more rapid bone healing so the fixator could be removed earlier. We have found this method to be easier to perform on a normally axed segment. This would require an initial subtraction osteotomy for prior alignment.

CONCLUSION

Forearm lengthening is a difficult procedure. Use of an intramedullary guide wire associated with an external fixation and an initial osteotomy for axial correction when needed and possibly stabilization of the wrist is an important contribution, particularly for malformed forearms.

[Conservative surgical treatment of osteogenic sarcoma of the limb in children and adolescents]

PURPOSE OF THE STUDY

Advances in chemotherapy protocols over the last 20 years have considerably improved the prognosis and functional outcome in patients with osteogenic sarcoma. We report here the results of a cooperative study conducted under the auspices of the French Society of Pediatric Oncology (SFOP). Twenty-nine oncology centers participated in this retrospective national multicentric study.

MATERIALS AND METHODS

The study included 153 patients with osteogenic sarcoma of the limb who were treated by the OS87 protocol with conservative surgery between 1987 and 1994. The OS87 protocol consisted in conservative or non-conservative surgery combined with pre- and postoperative chemotherapy. The following inclusion criteria were used: age under 20 years, tumor localization in a limb (pelvis and spine excluded), no metastasis at diagnosis, biopsy proven osteogenic sarcoma.

RESULTS

Mean age at diagnosis was 13 years. The knee localization predominated (80 p. 100). 82.5 p. 100 of the patients had grade IIB disease (Enneking classification). For the 187 patients included in the protocol surgery was non-conservative in 20 p. 100 of the cases and conservative in 80 p. 100. The choice of the surgical technique (arthroplasty, allograft, autograft, resection without reconstruction) depended on the patient's age and school situation. Data analyzed here concerned only those patients who had conservative treatment. Mean follow-up was 64 months. The actuarial survival curve plateaued at 71 p. 100 at more than 6 years. Early and late complications were numerous and variable (mechanical, infectious, local recurrence). Secondary amputation was required in 10 p. 100 of the patients. The overall functional outcome of the preserved limbs was nevertheless good with rapid restoration of self-sufficiency despite major surgery and a high number of reoperations (about 65 p. 100 of cases).

DISCUSSION

In light of the frequency and the seriousness of the complications, these results are modest. Patients and family should be advised of the risk, particularly the risk of secondary amputation which may be required early due to contaminated excision or at mid term due to major non-cancerological complications. As survival has been improved, functional capacity must be preserved for several years. This orients surgery towards more "biological" reconstruction which can provide greater longevity than arthroplasty.

[Sagittal equilibrium of the pelvis: analysis of the inclination of the ischio-pubic ramus from the horizontal]

PURPOSE OF THE STUDY

The sagittal equilibrium of the spine and pelvis has been examined in numerous studies looking for the origin of certain posture disorders of the spine and the cause of lower back pain. Sagittal x-rays of the pelvis provide an analysis of the degree of inclination of the pelvis from the horizontal and the bi-coxo-femoral axis and information on the form of the sacrum. There is no radiographic parameter however which analyzes the transition between the pelvis-sacrum component and the femoral component, i.e. the periacetabular region. In the sagittal plane, a line tangent to the ischio-pubic ramus would appear to best reflect the orientation of the periacetabular region and the muscular forces applied to this region. The purpose of this work was to analyze the inclination of the ischio-pubic ramus from the horizontal and its relations with other sagittal radiographic parameters in a population of growing children with spinal disorders.

MATERIALS AND METHOD

The study population included 100 children with spinal disorders who underwent a teleradiographic series with lateral view in the upright position. Most of the children had scoliosis (80 cases), 7 had kyphoscoliosis, 4 isthmic spondylolysis with spondylolisthesis, 1 spondylodiscitis and 4 lower back pain. Mean age was 13 years (range 2.5-22 years). We measured 7 radiographic parameters: lumbo-sacral angle, slope of the sacrum, pelvic version, incidence, thickness, overhang, and inclination of the ischio-pubic ramus from the horizontal. Data were analyzed to search for correlations between radiographic parameters and between radiographic parameters and clinical features.

RESULTS

Mean inclination of the ischio-pubic ramus from the horizontal was 33.9 degrees (SD =5.9 degrees ). The only positive statistical correlation between the inclination of the ischio-pubic ramus and the clinical data was a relationship with the position of the arms compared with the horizontal (p =0.04). There was no correlation with age, sex, ethnic background, etiology. There was no correlation between the inclination of the ischio-pubic ramus and the other radiographic parameters (coefficient r ranging from 0.06 to 0.43).

DISCUSSION

The interdependence of sagittal radiographic parameters of the pelvis and the spine have been largely demonstrated. Certain pathological situations (isthmic spondylolysis with spondylolisthesis, lower back pain, etc.) can be explained by the value of these parameters, particularly incidence. The inclination of the ischio-pubic ramus from the horizontal reflects the periacetabular region. When analyzed in the sagittal plane, it was found to be a more stable parameter, independent of most clinical criteria (particularly age, and etiology) and of the other radiographic parameters studied. The only determining factor appears to be acquisition of the upright position. The consistency of this parameter constrasts with the variability of the other radiographic parameters of the pelvis and the spine, particularly incidence, although the inclination of the ischio-pubis ramus is an expression of a region different than the pelvis. This study suggests that the periacetabular region plays a key role in acquisition of the upright position in humans. The periacetabular region would be a fixed point around which the lower limbs and spine describe varying orientations.

Functional results at the end of skeletal growth in 30 patients affected by congenital pseudoarthrosis of the tibia

From a multicentric study on Congenital Pseudoarthrosis of the tibia (CPT) conducted on 340 patients, we evaluated the functional results on a group of thirty patients who were at the end of skeletal growth (age < or = 16 years). The prognosis of CPT is very much related to the radiologic classification. Crawford type 2 and Crawford type 4 pseudoarthrosis have a worse prognosis, with a lower percentage of fusion at the site of pseudoarthrosis. Crawford 4 patients have the worst functional results. Most of them showed a severe leg length discrepancy, needed a permanent brace, with an ankle joint function fair or poor. The presence of fibula pseudoarthrosis seems to be responsible for most of the worst functional results. The level of deformity caused by either the natural course of the disease or its treatment, is decisive in the evaluation of the functional results.

Treatment approaches for congenital pseudarthrosis of tibia: results of the EPOS multicenter study. European Paediatric Orthopaedic Society (EPOS)

This study was designed to analyze the different therapeutic methods used by European Paediatric Orthopaedic Society members from 13 countries for congenital pseudarthrosis of tibia. The treatment data of 340 patients who underwent 1287 procedures for this condition were analyzed. The essential findings were that the method of choice needed to approach the biological problem with the aims of: (1) resecting the pseudarthrosis to provide stability, the basic requirement for bony consolidation; (2) correcting length discrepancy and axial deformity; (3) achieving fusion; and (4) solving the additional problems around the main deformity such as alignment, leg length discrepancy and ankle valgus. The Ilizarov technique emerged as being the optimal method, having the highest rate of fusion (75.5%) of pseudarthrosis and rate of success in correction of the additional deformities. There was also consensus that surgery should be avoided before the third year of life.

Free vascular fibular transfer in congenital pseudoarthrosis of the tibia: results of the EPOS multicenter study. European Paediatric Orthopaedic Society (EPOS)

This paper presents a review of the literature, describes the principal author's (B.R.) personal experience and provides the results of the European Paediatric Orthopaedic Society (EPOS) multicenter study. The objective is to evaluate the present status and future role of free vascular fibular transfer in treating congenital pseudoarthrosis of the tibia. Variables such as the selection of cases, age at operation, technical surgical details and postoperative results will be considered. The data on the EPOS study were incomplete at the time of writing, but the considerable amount of information already amassed is a valuable contribution to this updated report.

The fibula in congenital pseudoarthrosis of the tibia: the EPOS multicenter study. European Paediatric Orthopaedic Society (EPOS)

Fibular involvement in congenital pseudoarthrosis of the tibia (CPT) can be either a rare isolated pathology or is in association with the tibial changes. Out of 282 patients with CPT who had complete radiographic work-up, 62% (almost two thirds) demonstrated fibular pathology: 36% had true fibular pseudoarthrosis and the rest, i.e., 26% had fibular hypoplasia or dysplastic fibula. Neurofibromatosis was found in 62% of the patients with fibular pathology. The typical radiological features of tibial pseudoarthrosis are often missing in patients with fibular pathology. It is most probably because fibular changes precede the tibial involvement. In 250 patients with tibial surgical treatment, the highest rate of fusion occurred in patients with fibular involvement compared with those with normal fibula.

Delayed cure of an omphalocele requiring abdominosternoplasty, right hepatectomy and partial splenectomy

A large ventral hernia resulting from the primary treatment of an omphalocele according to the Gross technique was repaired at age 16. The girl presented with extra-abdominal development of the liver and the spleen along with hypotrophy of the abdominal and thoracic cavities. The operation included enlargement sternoplasty, liver and spleen-size reduction and prosthetic abdominal closure. The cosmetic and functional results are good and stable on 7-year follow-up. Surgical issues and blood transfusion policy are discussed. A multi-disciplinary pediatric surgical approach is advocated.

Congenital pseudarthrosis of the tibia: history, etiology, classification, and epidemiologic data

Congenital pseudarthrosis of the tibia is a rare disease with a variable history. The pseudarthrosis is usually not present at birth (and therefore is not truly congenital) but occurs during the first decade of life. Paget in 1891 was the first to describe a case. The etiology is unknown. Neurofibromatosis plays a role in approximately 50% of patients. In the others, hereditary and mechanical factors are debated. Various (morphologic) classification systems have been proposed (Andersen, Boyd, Crawford). Because the appearance changes during the course of the disease, all classification systems have limited value: the determining factor is the stage of the disease at which it was classified. Because of the rarity of the disease and the variability of its history, the European Pediatric Orthopaedic Society decided to carry out a multicenter study on this disease. This paper presents the epidemiologic data on the patients involved. Data have been gathered on 340 patients from 13 countries. Two hundred patients were male (58.8%), 140 were female (41.2%). The right side was affected in 165 patients (48.5%) and the left side in 172 (50.6%); 3 patients had bilateral disease. Symptoms of neurofibromatosis were present in 54.7%. Histologic examinations in 192 patients showed a nonspecific appearance in 45.3%; in 15.6% the ultrastructure resembled fibrous dysplasia, and in 39% there was histologic evidence of neurofibromatosis. Most of the lesions were initially localized in the middle or distal third of the tibia. In 29% the localization changed during the course of the disease.

[Pseudo-paralysis of the brachial biceps in obstetrical brachial plexus lesions (OBPL):concerning the "overly optimistic" EMG in OBPL]

In birth palsy of the brachial plexus, the mixed interference pattern recorded for the brachial biceps on the electromyogram often conflicts with the muscle's inability to flex the elbow. We report our observations of a six-month-old infant who presented paralysis of the upper and medial elements of the brachial plexus, in whom we demonstrated early biceps-triceps co-contractions, which may explain this discrepancy and 'pseudo-paralysis' of the biceps. We analyse and discuss the practical consequences of these findings, and notably the possible therapeutic use of triceps-to-biceps surgical transposition.

[Osteopetrosis: diagnostic and therapeutic management. Apropos of 5 cases]

PURPOSE OF THE STUDY

The purpose of this study was to analyse 5 cases of osteopetrosis: 2 dominant and 3 recessive forms.

MATERIAL AND METHODS

Among five cases of children suffering from osteopetrosis. There were three malignant and two benign forms. Three children affected by malignant form, received a bone marrow transplantation.

RESULTS

Only one child who received a bone marrow transplantation was still alive and cured (one died due to transplantation complications, the other child died accidentally). The two children presenting a benign form were periodically followed for iterative fractures and did not present serious complications.

DISCUSSION

Our analysis compared to literature review allows us to insist on bone marrow transplantation. This is the only possibility for these children who were condemned in the past. The frequency of iterative fractures on children presenting a dominant form necessitates medical and orthopedic follow-up. Narrowness of the medullary canal, bone fragility contra indicates intramedullary nailing when fixation is indicated.

CONCLUSION

Osteopetrosis is an autosomal metabolic bone disease caused by an anomaly of osteoclasts action. Two main forms exist: the dominant form which is benign, and the recessive form which is malignant. Actually recessive forms can be treated and cured by bone marrow transplantation and the children who were in the past condemned are saved. Children with dominant form must be followed up by an orthopaedic surgeon because of bone weakness. The increase in number of cases detected in immigrant populations with a high rate of consanguineous marriages led us to present this study.

[Idiopathic scoliosis: evaluation of the results]

Natural history studies in idiopathic scoliosis must be known to assess the effectiveness of treatment. Natural history is better known to day for mild angulations but as far as scoliosis are operated on for greater angulations natural history of scoliotic population with Cobb angle greater than fifty degrees is less and less available. Effectiveness of school screening is debated because of over-referral of either non scoliotic children or patient with mild non evolutive scoliosis. Attempt to find any criteria for evolutive scoliosis was disappointing. Only scoliosis with Cobb angle greater than thirty five degrees during growth spurt is defined as an evolutive scoliosis with a 95% confidence interval. Scoliotic curves show a tendency to progress even during adult life especially if the Cobb angle is over thirty degrees at skeletal maturity. Effectiveness of bracing is established for Cobb angle over thirty degrees. Comparing natural history and the results of bracing for mild idiopathic scoliosis controversies remain according to the effectiveness of bracing. Scoliotic population is more at risk for back pain than a population based control group. In severe idiopathic scoliosis non operated patients ar more at risk for back pain than operated one. Multi-hooks systems used for surgical correction of scoliosis are helpful in term of coronal plan correction but no system effectively derotates the spine. Scoliotic population experiences significatively more back pain than control group. There is a higher prevalence of negative perception of health but a more positive perception of self in the scoliotic population compared to a control group.

[Iterative fractures in type I primary hyperoxaluria. Report of 2 cases]

PURPOSE OF THE STUDY

Type I primary hyperoxaluria is a rare autosomal recessive disease linked to a deficit in an hepatic enzyme. The purpose of this study was to analyze orthopedics problems caused by type I primary hyperoxaluria before and after liver and kidney transplantation.

MATERIAL AND METHODS

Two cases of children carrying this type I primary hyperoxaluria followed up after liver kidney transplantation are presented and compared to last publications.

RESULTS

Combined transplantation progressively corrected osseous lesions and aspect of the stroma. However it did not provide protection against fractures particularly for femoral neck fractures.

DISCUSSION

In type I hyperoxaluria overproduction of calcium oxalate causes its accumulation in the whole organism and particularly in bone. Osseous fragility favors pathological fractures. Only combined liverkidney transplantation can save and cure these children. Frequency of this fracture after transplantation indicates preventive plating at first pain, possibly at the same time as transplantation. Kidney transplant failure puts the patient in a "congealed" clinical state where the bone is very rich in oxalate and where the hemodialysis does not eliminate oxalate salts.

CONCLUSION

Type I primary hyperoxaluria is a very rare disease. Fractures are very common even after liver and kidney transplantation and especialy femoral neck fractures. We think that preventive plating must be done at first pain. We do not have any explanation for bony weakness after liver-kidney transplantation.

[Autonomy of the nursing profession: state of the art]

This article points out the foundation elements of the nursing education, the way covered till now, the status of the art and what has to be achieved in order to attain Nursing Degree objectives. The different aspects concerning the curricula organization and the model of care are examined. The request of getting nursing teaching and nursing chairs for nurses are an aim not yet met, but they are the basis objectives of the professional engagement. Another important subject concerns the leadership that will allow nurses to be administrators and managers in every respect, also from a juridical point of view, and to express their professionality in a really autonomous way.

Aneurysmal bone cyst in children: analysis of twenty-seven patients

The authors have analyzed a retrospective series of 27 aneurysmal bone cysts (ABCs) in children and adolescents. The average age at diagnosis was 10 years (range: 3 years 7 months to 16 years), with a mean follow-up of 5 years (range: 1 month to 13 years 9 months). Pathologic fractures (8 cases) and pain (8 cases) were the main reasons for consultation. Of five spinal ABC patients, four presented with neurologic involvement. Although conventional radiology is useful for diagnosing ABCs, magnetic resonance imaging (MRI) is nevertheless the most important technique for checking the extent of the lesions. However, the diagnosis still must be based on the pathologic laboratory findings, even though this is sometimes difficult because of associated lesions. In lesions of the long bones, recurrence was observed after curettage in 5 of 12 cases. For this reason, simple resection or resection with reconstruction is recommended rather than curettage whenever possible. When an ABC is in contact with the growth plate in young children, blunt curettage should be performed to preserve the child's growth potential. Subsequent recurrence usually is easier to treat than an epiphysiodesis bridge and its consequences. The surgical procedures used to preserve the growth plate are described, along with methods of bone construction after surgery.

Five cases of Kingella kingae skeletal infection in a French hospital

Five cases of Kingella kingae skeletal infections were diagnosed in children admitted to La Timone Hospital between 1992 and 1997. Patients were between 6 and 31 months old and presented with septic spondylodiskitis, calcaneus osteomyelitis, and hip-joint arthritis. All displayed either an upper respiratory tract infection or eczema during the month prior to their admission. Laboratory findings included an elevated leukocyte count and an elevated erythrocyte sedimentation rate. Standard radiography was unrevealing, but 99mTc bone scans and magnetic resonance imaging showed significant abnormalities. Isolation of Kingella kingae was achieved in all cases by culture of fluid aspirates using the Bactec blood culture system. This bacterium was sensitive to the most common antibiotics tested, and the outcome was favourable in all cases.

[Lower limb morphotypes. A clinical study in 1401 children]

PURPOSE OF THE STUDY

The purpose of this study was to analyse the repartition between femoral anteversion and tibial torsion from birth to ten years of age in children.

MATERIAL

One thousand four hundred and one children ranging from 2 to 13 years age were examined in public schools by the same clinician.

METHODS

Qualitative data (foot progression angle, hindfoot aspect, knee position during gait) and quantitative data (femoral anteversion, tibial torsion) were clinically quantified.

RESULTS

Repartition of femoral and tibial torsion showed four lower limb morphotypes in normal children.

CONCLUSION

Four femoral anteversion and tibial torsion associations are encountered in normal children. Age variation of the lower limb orientation leed to have repetitive examinations in children with in or out-toeing gait in order to make distinction between normal and pathologic gait pattern.

Reimplantation of growth plate chondrocyte cultures in central growth plate defects: Part I. Characterization of cultures

Growth plate lesions or resections may cause severe growth arrest because of the bony bridge between the epiphysis and metaphysis. Actual treatments for epiphysiodesis include resecting the bone bar and setting an interpositional material. Growth plate cultures may provide the appropriate cartilage necessary to restore growth potential when implanted in a growth plate defect. The aim of this work was to determine certain cell culture parameters in order to optimize in vitro cultures to obtain abundantly mature and functional chondrocytes. We studied the manner in which enzymatic digestion, carried out by various enzymes, obtained chondrocytes. Treatment with trypsin (0.2%) during 30 minutes at 37 degrees C and then collagenase (200 U/mL) during 6 hours was chosen. Under these conditions, 40 +/- 16 10(6) chondrocytes per gram of growth plate were obtained, and cellular viability was 79 +/- 12%. The density of the cellular seeding, the nature of the culture substrate, and the culture medium composition were determined to optimize the growth of differentiated cells. Seeding at 20,000 or 30,000/cm2 on a type I substrate and Ham F-12 medium not supplemented with either glucose or growth factors was demonstrated to be the best choice for this purpose.

Reimplantation of growth plate chondrocyte cultures in central growth plate defects: Part II. Surgical experimentation in rabbits

An original and reliable technique to culture growth plate chondrocytes was developed to obtain an abundant amount of mature and functional chondrocytes. Growth plates were provided from the epiphysis of 3-week-old rabbits. Isolation of the chondrocytes was optimized by the use of trypsin and collagenase. The culture was realized according to the following conditions: seeding at 20,000 or 30,000/cm2 on type I collagen substrate and in Ham F-12 medium without a supplementation of glucose or growth factors. After 7 days of culture, the implantation was to be carried out. Different implantation substrates were evaluated in vivo. Agar turned out to be the only substrate to provide strong and healthy chondrocytes 21 days after the grafting. Then implantation was tested on large iliac resections in rabbits to check whether an enchondral ossification occurred with the culture. Poor results were obtained because of an early disappearance of the cultured chondrocytes. In an other experimentation, the culture was implanted into surgically created defects in the growth plate area. In this case, the culture did produce an epiphysiodesis. However, the 6-week postoperative histological examination showed that the implant remained viable, continued to maintain a proteoglycanrich matrix, and began to organize in ordered columns of mature chondrocytes.

[Focal fibrocartilaginous dysplasia and tibia vara. Apropos of 2 cases. Review of the literature]

Focal cartilaginous dysplasia is a rare condition associated with unilateral tibia vara in young children. The authors report 2 cases. In one patient spontaneous correction occurred at the age of 18 months. In the other case the patient's deformity persisted, and an osteotomy was performed at the age of 36 months. Through these 2 cases and 26 cases of the literature, the authors discuss the healing process and etiology. The most likely exploration is an abnormal development at the insertion of the pes anserinus inducing epiphysiodese like effect. In most cases, the growth plate of the proximal tibial appears to correct the deformity. Surgical correction is necessary after the age of 36 months, if the angular deformation is up to 30 degrees of varus.

Myositis ossificans: report of seven cases in children

The clinical features of seven children with myositis ossificans (circumscripta and progressiva) and radiographic signs of the disease are described. We recommend systematic radiological examination to seek other skeletal malformations for congenital hallux valgus in young children, for it may be the first sign of a myositis ossificans progressiva. The "zone phenomenon" observed on histology, along with differential diagnosis and evolution, is documented. The necessity of a biopsy and different forms of treatment are discussed.

Epiphyseal distraction and centrally located bone bar: an experimental study in the rabbit

The purpose of this study was to analyze the force required for an epiphysiolysis in vitro in the distal femoral growth plate of rabbits with different sized central physeal bone bars. The bars were operatively induced by drilling through the physis. An epiphyseal distraction was then performed, and the response was evaluated. Forty rabbits (67 femurs) divided into five groups were used for experimentation. Group A had not been operated on and manifested no physeal bone bridge. Groups B, C, D, and E manifested some bone bridges obtained surgically by drills 2, 2.5, 3.5, and 4.5 mm in diameter, respectively. The average force required to obtain an epiphysiolysis is not statistically significant in the different groups. However, we noted that the epiphysiolysis differed depending on the diameter of the surgically performed bridge. Group E was Salter-Harris type II fractures, whereas groups A, B, and C were type I fractures. Group D comprised both types.

Acute fracture of the distal tibial physis: role of gradient-echo MR imaging versus plain film examination

OBJECTIVE

Recent reports indicate that, compared with MR imaging, plain film radiography often underestimates the extent of injury in children with physeal fracture-separation. Such underestimation may have significant therapeutic and prognostic outcomes. We performed this study to assess the benefit of MR imaging compared with plain film radiography in the diagnosis and immediate treatment of acute fractures of the distal tibial physis.

SUBJECTS AND METHODS

Twenty-nine patients with acute fractures, including 15 Salter-Harris II, four Salter-Harris III, four Salter-Harris IV, and six triplane fractures, were prospectively examined by MR imaging with gradient-echo sequences. The MR images were compared with plain film radiographs. All cases were reviewed in a blind fashion by two experienced radiologists to determine the Salter-Harris classification on the basis of first plain film radiographs and then MR images. Two experienced pediatric surgeons were asked to propose treatment on the basis of first plain film radiographs and then MR images. Both the radiologists and the surgeons were asked to rate the two techniques in terms of degree of confidence and overall diagnostic effectiveness.

RESULTS

Only 1 or 29 fractures (3%) was misclassified by plain film radiography. MR imaging never caused the treatment plan to be modified. However, the position of fracture fragments in Salter-Harris IV and triplane fractures was always better appreciated on MR images, facilitating more accurate surgical treatment. Except for those in the misclassified fracture, all other fracture lines were seen on both plain film radiographs and MR images but were more easily seen on MR images.

CONCLUSION

Gradient-echo MR imaging allowed easier assessment of fracture lines than did plain film radiography, but the latter technique remains the primary means of evaluating epiphyseal injuries. For acute fractures of the lower extremity of the tibia, gradient-echo MR imaging should be limited to complex fractures and to cases in which the classification of a fracture on the basis of plain film evaluation is uncertain.

[Munchmeyer's disease in children]

The clinical features of two children with myositis ossificans progressiva are described. Skeletal malformations can be observed in many sites: hand, femur, tibia and spine. Phalangeal abnormalities (shortened hallux, hallux valgus) are essential to the diagnosis. We recommend systematic roentgenographic examination to search for other skeletal malformations for congenital hallux valgus in young children because it can be the first sign of myositis ossificans progressiva. Progression of disability does not seem to be influenced by any form of medical treatment. Surgical removal of ectopic bone is thought to be followed inevitably by rapid recalcification at the original site.

Osteoarticular infection due to Coxiella burnetii in children

We report three cases of chronic osteoarticular infections associated with Q fever in children. In two of them, serologic diagnosis was confirmed by direct immunofluorescence of Coxiella burnetii in the synovial and bone biopsy specimen. We suspect that bone infections due to Coxiella burnetii could be underdiagnosed because this etiology is not frequently seen.

[Closed spinal dysraphism]

This retrospective review included 133 patients with one or several of the following defects: diastematomyelia, neurenteric cyst, dermal sinus or cyst, meningeal malformation, sacral agenesis, tethering of the spinal cord, and lumbosacral lipoma. Physical evaluation readily identified most lumbosacral lipomas, as well as most cases of diastematomyelia since hypertrichosis over the defect was common. Some patients developed life-threatening clinical manifestations, e.g., meningitis due to a dermal sinus. On the basis of this retrospective review and a review of the literature, the clinical and therapeutic aspects of each defect are discussed.

Physeal and epiphyseal extent of primary malignant bone tumors in childhood. Correlation of preoperative MRI and the pathologic examination

Twenty-two patients with metaphyseal primary malignant bone tumors (17 osteosarcomas, 5 Ewing's tumors) occurring before closure of the growth plate were examined with plain radiographs and MRI in order to determine the physeal or epiphyseal extent of the tumor. Results were correlated with the pathologic examination. Transphyseal spread was pathologically proven in 13 cases (59%): 12 cases of osteosarcoma and 1 case of Ewing's tumor (70% and 20%, respectively). There was no significant relation between epiphyseal invasion, age of patient, length of tumor or, in the cases of osteosarcoma, response to chemotherapy. Plain radiographs showed epiphyseal involvement in 4 cases and there were 10 false negatives. MRI revealed epiphyseal involvement in all cases; there were no false positives or false negatives. T1-weighted images in coronal or sagittal planes appeared to be sufficient. These findings are very useful in planning surgical limb salvage procedures and stress the ineffectiveness of the "barrier effect" of the growth plate against tumor spread.

Acetabular anteversion in children

Acetabular anteversion analysis was performed in 143 normal children, who ranged in age from 1 to 15 years. The mean anteversion value, which remained constant during growth, was 13 degrees.

Bone lesions in histiocytosis X

Sixty-two patients with histiocytosis X were followed for an average of 5 years. The patients were classified into three groups: general visceral types (14 cases), multiple eosinophilic granulomas (nine cases), and solitary eosinophilic granulomas (39 cases). One hundred bony lesions were noted in 60 of the 62 patients. The bone lesions showed progressive improvement in single and multiple eosinophilic granulomas independent of treatment type. After biopsy, patients received no treatment unless there was a dangerous extension into the soft tissues because of its site, i.e., in the skull. In the general visceral types, chemotherapy was effective in visceral sites and in extensions of the tumor outside the bone but did not alter the natural history of the bony lesion.

[15 cases of vertebral involvement of histiocytosis X in children. Review of the literature]

Fifteen pediatric cases of vertebral involvement in histiocytosis X are reported. The study of these cases and a review of the literature shows that every patient with histiocytosis X should have a local and systemic staging work-up to differentiate isolated eosinophilic granulomas of the bone, multiple eosinophilic granulomas of the bone, and visceral disseminated disease. Management varies according to the extension of the disease. Systemic chemotherapy may be indicated in patients with extraosseous lesions. Local investigations should be performed to look for instability of the spine, which may require surgery, and above all for spread to the soft parts indicating chemotherapy with or without surgery. Forms which are strictly confined to the bone and cause no instability, such as vertebra plana, require no treatment.

Biomechanical analysis of the Chiari pelvic osteotomy. Preserving hip abductor strength

Although the Chiari osteotomy is usually effective in reducing pain, many patients are left with a long-term limp. The postoperative limp can at times be caused by hip abductors that have strength insufficient to counteract the torque from body weight during single-leg stance. To study how the surgical technique affects the hip abductor muscles, a biomechanical model was developed that computes the postsurgery pelvic geometry and the resulting hip abductor torque given three surgical parameters: angulation of the osteotomy, distance of medical displacement, and angle of internal rotation. The computer simulations of the Chiari osteotomy showed that some sets of surgical parameters conserve abductor torque while others greatly reduce it. Simulated surgeries with high angulation and large medial displacement reduce gluteus medius abductor torque by up to 65%. Therefore, this combination of surgical parameters may account for some instances of the postoperative limp. In the model, high angulation reduces the length of the gluteus medius and is the primary cause of reduced abductor strength. Simulated horizontal osteotomies (0 degrees to 10 degrees) were found to best conserve both muscle length and abductor torque.

MRI of disc space infection in infants and children. Report of 12 cases

The MR aspects of spondylodiscitis in pediatric patients were studied with a 0.5-Tesla supraconductive magnet: 12 patients were divided in two groups; acute disease (9) and period of sequelae (3). The first group was divided into two subgroups according to the age and the clinical findings: infants (2) and children (7). In infants, MR gave good visualization of the destruction of vertebrae and discs. Presuppurative abscesses appeared as light signals, their extent and position relative to the cord being clearly visualized in frontal and sagittal planes in T1-weighted images. In older children, there were a low vertebral signal and disappearance of the disc-vertebra borders on T1-weighted images and a high vertebral signal with a decreased and flattened disc signal on T2-weighted images. Frontal and sagittal planes were used. During the first month of antibiotic therapy, the follow-up scans showed no changes, and even disclosed a spread of the abnormal signal in the vertebral body. At the stage of sequelae, on T1 the spinal signal was normal with a decreased disc width and on T2 the disc signal was low while the vertebrae appeared normal.

Is the Cotrel-Dubousset really universal in the surgical treatment of idiopathic scoliosis?

We reviewed the results of 22 cases of Cotrel-Dubousset (C-D) instrumentation, 16 cases of anterior approach, and 200 cases of posterior approach by Harrington instrumentation and modifications of Harrington procedure. Posterior spinal fusion and instrumentation by C-D gives better correction and stabilization in thoracic and balanced double major curves. We no longer use the Harrington procedure and its modification. In lumbar and short thoracolumbar curves, VDS is still preferred. In some double major curves combined procedures, VDS and C-D are used to obtain more correction with a shorter fusion area.

Excision of hemivertebrae in children with congenital scoliosis

This study reports the authors' experience with excision of hemivertebrae in the treatment of congenital scoliosis. Although it is limited to 10 cases, it is significant because of the 9 years follow-up. The first patients treated have already passed the age of puberty and this is the most interesting aspect of the study.

[Disk calcifications in children. Apropos of 17 cases]

Seventeen cases of calcification of the intervertebral discs in childhood have been seen. Only cervical lesions gave symptoms. In several cases the lesions were multifocal (cervical and thoracic) and there was a familial history in one case. Two cases were observed for 10 and 8 years respectively. It was noted that cervical calcifications tend to disappear while thoracic ones persist but are asymptomatic. The authors postulate that this is due to differences in the physiology of the nucleus and in the biomechanics at different levels of the spine. A high frequency of associated spinal deformities was noted. For this reason, the late prognosis must be guarded.