Purpose of the study: Malignant tumours of the thoracic wall are rare. Treatment protocols include extensive surgical resection. In children, these resections can generate very severely progressive scoliosis. We studied the local conditions favouring the development of scoliosis in a consecutive series of eight patients.

Material and methods: From November 2004 to December 2007, six boys and two girls, mean age 7.6 years (range 4 months – 15 years) underwent extensive thoracic wall resection for a malignant tumour: Ewing sarcoma (n=5), spindle-cell sarcoma (n=2), neuroblastoma (n=1). All patients received adjuvant chemotherapy followed by resection removing on average 3.1 rigs (range 1 – 4 ribs). Six resections involved the costovertebral angle and three were associated with partial pneumonectomy. The number of ribs resected was noted in Roman numerals. The thoracic wall was divided into three sectors in the horizontal plane according to the level of the resection (A, B, and C, posteriorly to anteriorly). Reconstruction was achieved with a Gortex plaque (n=1), Borreli staples (n=2). Posterior spinal instrumentation was performed in one patient. Despite in sano resection, six patients underwent postoperative radiotherapy.

Results: At mean 2.9 years follow-up (range 1 – 5 years), four patients of the eight developed scoliosis convex on the operated side. These patients had IVA resections for three patients (50, 50 and 32° scoliosis) and type IA-IIB for one patients (13° scoliosis). These deformities occurred despite a corset and instrumentation in one patient. None of the patients had a humpback. Patients who did not develop scoliosis had resections IA-IIB, IA-IB, IVC and, IC.

Discussion: The type of reconstruction, the histological type, use of complementary postoperative radiotherapy or pulmonary resection did not appear to be factors favouring the development of scoliosis. Conversely, resection in zone A (posterior) over more than two adjacent levels, might be a predictive element of the risk of scoliosis.

Conclusion: In the event of a resection of ribs in a posterior zone over more than two levels for resection of a malignant tumour, posterior instrumentation should be discussed. This preliminary work offers evidence for thought but needs to be strengthened with a multicentric study to enable a statistical analysis.

Background: The medial patellofemoral ligament (MPFL) is the primary stabilizer of the patellofemoral joint. Its reconstruction has been recommended in adults over the past decade after recurrent patellar instability. The purpose of this study was to assess outcomes after MPFL reconstruction in children and adolescent and to prospectively evaluate reconstruction by computed tomography (CT scans) before and after surgery.

Materials and Methods: Thirteen consecutive patients (5 boys and 8 girls)(13 knees) underwent a double bundle MPFL reconstruction with hamstring tendon autograft (gracilis:6, semitendinosus: 7) for patellar instability. A bone femoral fixation with interference screw in a tunnel was associated with patellar fixation according to Fithian in mature knees, and a soft tissue procedure was performed in skeletally immature knees. In 5 knees the MPFL reconstruction was isolated while it was associated with medialization and distalization of the tibial tubercle in 8 knees. The mean age at time of surgery was 14.4 years (range, 9.6– 16.5). Patients were evaluated preoperatively and postoperatively by physical, radiological and CT Scans examination and subjectively with the IKDC and Kujala questionnaires. During CT scans with knee fully extended and the quadriceps contracted or relaxed, the patellar tilt angle was assessed. In cases where tibial tubercle was mobilized, the tibial tubercle-trochlear groove (TT-TG) distance was measured pre and postoperatively.

Results: No recurrent episodes of dislocation or sub-luxation were reported after 10.5 months (range, 3–23) follow-up after surgery. Mean Kujala score was of 90.2 (range, 84–99) at latest follow-up. For all patients the moving patellar apprehension test was positive before and negative after surgery. A firm end point to lateral patellar translation was noticed in all patients at latest follow-up. Objective assessment with CT noted that the patellar tilt on relaxed quadriceps was significantly improved from 28° preoperatively (range, 16–41) to 16° at follow-up (range, 7–32). The patellar tilt on contracted quadriceps was significantly improved from 35° preoperatively (range, 21–52) to 24.6° at follow-up (range, 11–48). In the specific subgroup, the TT-TG distance decreased preoperatively from 15.4 mm (range, 12–19) to 9 mm postoperatively (range, 2.9–14.8).

Conclusion: MPFL reconstruction in children and adolescent is an effective procedure. The patellar tilt was efficiently improved by MPFL reconstruction and these results were correlated with Kujala score. Mid and long term results are still to be evaluated.

The purpose of this study was to compare 2 different strategies of management for ACL rupture in skeletally immature patient.

In group 1, patients were treated in a children hospital by ACL reconstruction with open physis. In group 2, patients were treated in an adult hospital by delayed reconstruction at skeletal maturity assessed radiologically.

Fifty six consecutive patients were included in this retrospective study. Mean time from injury to surgery in group 1 and 2, was 13.5 and 30 months, respectively.

In the overall series, a long time from injury to surgery increased the number of medial meniscal tear (p< 0.0001), but had no influence in the number of lateral meniscal tear (p=0.696). Patients in group 2 exhibited a higher rate of medial meniscal tears (41%) compared to group 1 (16%) (p=0.01). Both groups had the same rate of lateral meniscal tears (p=1). Despite there was no difference between the 2 studied groups in type and location of menisci lesion, patients in group 2 underwent more partial menisectomy (63%) than patients in group 1 (16%) (p=0,014).

One temporary tibial valgus deformity was reported and spontaneously resolved. No definitive growth disturbance was noticed. At 27 months mean follow-up, patients in group 1 expressed better subjective IKDC than in group 2. Objective IKDC and radiological results were similar in both groups.

Early ACL reconstruction in skeletally immature patient, especially if the patient is more than one year to be skeletally mature, has to be promoted despite of growth disturbance risk. This strategy will decrease medial meniscus lesions and partial meniscectomies which occurred more frequently when ACL reconstruction had been delayed until skeletal maturity.

Introduction: The aim of this study was to identify the pattern of symptoms in patients presenting with synovial sarcoma, examine how these corresponded to the symptoms outlined by the NICE guidelines on the rapid referral of patients with a suspected sarcoma and spot factors that led to long delays in diagnosis.

Methods: Early symptoms and the results of clinical and radiological investigation were reviewed along with the presumed diagnoses that had been made for 35 children. The total duration of symptoms was separated into patient delay and doctor delay.

Results: Using the four clinical findings suggestive of sarcoma according to the NICE guidance, only half of the patients had one or more of them at the time of initial symptoms. The most common presentation was a painless mass (n=16), and in 10 children there was no mass identified. Seven patients had an inexplicable joint contracture, many having been extensively investigated unsuccessfully. The mean duration of symptoms before the diagnosis was made was 98 weeks (range 2 to 364). The mean number of doctors seen prior to referral was 3 (range 1–6) and for 15 patients the diagnosis was obtained after inadvertent excision. The factors associated with long duration of symptoms before diagnosis were knee and elbow location (p=0.0047) or periarticular location (p=0.01), absence of lump (p=0.016) or painful mass as early symptom (p=0.04), the presence of calcifications on x-rays (p=0.01) and a fixed joint contracture (p=0.0003).

We could not show that delay in diagnosis led to a worse prognosis.

Discussion: This paper highlights the sometimes bizarre symptoms associated with synovial sarcoma and hopefully this will increase awareness of the condition among relevant sections of the medical profession and help to reduce the delay in diagnosing these cases.

Purpose of the study: We conducted an experimental study of the effects of rh-BMP-7 on healing rate in the tibia of the immature rabbit exposed to bone distraction. As seen in previous models using bone stock loss or lumbar fusion, we hypothesized that rh-BMP-7 accelerates osteogenesis of the distracted segment.

Material and methods: Twenty-eight immature male New Zealand rabbits weighing 2 to 3 kg were randomly selected from a homogeneous population. Two groups of 14 rabbits were constituted by random selection: the control group (group I) and the BMP group (group II). An Orthofix M-103 external fixator was installed on the left tibia in all rabbits before performing a mid-shaft osteotomy. 70 g rh-BMP-7 was applied to the osteotomy surfaces in group II animals. After a postoperative latency period of 7 days, bone distraction was instituted at the rate of 0.5 mm/12 hr for 21 days in all animals. Radiographic qualitative grading, ultrasonography, and bone mineral density measurements on the callus were performed each week on each animal from the second week to sacrifice. After sacrifice, the distracted callus was removed and embedded in resin for histomorpho-metric analysis without decalcification.

Results: Two animals from each group were excluded from the analysis because of a fracture on the pin line of the operated tibia. There were no wound or pin track infections. The radiographic grade noted in group I was constantly greater than in group II. Bone mineral content was significantly higher in group I animals compared with group II. The ultrasound examination of the callus revealed more rapid distraction gap filling in group I than group II. An liquid-filled cyst was noted early in 92% of the rabbits in group II, which retarded osteogenesis. This type of cyst was not observed in any of the group I animals. At the time of sacrifice, the ultrasound and bone density measurements tended toward similar values in the two groups, the results for group II catching up with those for group I. This trend was concomitant with resolution of the cysts within the callus in group II animals. The histological examination demonstrated earlier osteogenesis and remodeling in group I animals.

Discussion: Early formation of cysts would be the only factor causing late maturation of the callus in group II. The fact that the results tended toward similar values for the ultrasound and bone density studies late in the study (when the cysts were being resorbed) favors this hypothesis. Interposing rh-BMP-7 in solid form between the osteotomy surfaces may have inhibited the formation of the primary callus and caused an inflammatory reaction with cyst formation. The rh-BMP-7 may have been applied to early or may in itself had a negative effect, which might explain the absence of the expected acceleration of healing.

Conclusion: Early local application of 70 g rh-BMP-7 on osteotomy section surfaces in a rabbit model of tibial distraction did not lead to expected accelerated healing rate. The application of this compound after formation of a primary callus or in another formulation (liquid) might avoid the development of cysts within the callus and allow the active substance to play is potential role as an accelerator of bone healing.

Purpose of the study: Determining bone age at the wrist is not an easy task and can be a source of error. We elaborated a method for determining bone age at the elbow using an analysis of bone maturation at this localization.

Material and methods: The method finetunes the Sauvegrain method and is based on more than ten years of data for the analysis of more than 3600 x-rays. Bone maturation evolves from 0% at birth to 100% marking the end of growth. We propose a digital system for drawing the growth curve from 50% to 100% bone maturation as a function of chronological age. This curve gives the distribution of bone age around the median for each gender. Fifty percent maturation corresponds to onset of adolescence and can be used to define onset of puberty before any other clinical sign; 100% bone maturation corresponds to maximal growth or stature. Specific bone landmarks are used and the method for calculating bone age is presented.

Results: It is interesting that a shift of one year or more between bone age calculated at the elbow and that calculated from the wrist. This observation was frequent and suggests that bone age determined at the elbow gives a better reflection of limb maturation. In addition, regular use of this method in daily practice confirmed its usefulness, reliability, and inter- and intra-observer reproducibility.

Conclusion: This is a reliable simple method for determining bone maturation. It is easier to use than the wrist method and probably better reflects bone maturation of the limbs.

Purpose of the study: Chondroblastoma is a rare benign cartilage tumor usually observed in secondary ossification centers of long bone in subjects aged 10 to 20 years. We report a multicentric series of 63 cases of chondro-blastoma in children and attempt to identify particular pediatric epidemiological features and identify factors of risk of recurrence.

Material and methods: Clinical data an pre and postoperative imaging were analyzed as well as the histological findings reported by one observer. Files were collected from ten pediatric orthopedic units in France (two in Lyon, three in Paris, Rennes, Strasbourg, Toulouse, Saint-Etienne, Nice). Data were stored in a single database. The series included 35 boys, and 29 girls (sex ratio 1.25=. Mean age at diagnosis was 12 years (18 months to 17 years), 13 years for boys and 11 years for girls. Tumors were located in the epiphysis of the proximal tibia (n=17), the proximal femur (n=16), proximal the humerus (n=16), the distal femur (n=4), tarsal bones (n=4), the distal tibia (n=2), the fibula (n=2), the pelvis (n=1) and the distal radius (n=1). Preoperatively, the Springfield classification was: latent (n=14), active (n=36), aggressive (n=8); five tumors could not be classified. Treatment consisted in curettage-graft (n=40), curettage alone (n=17), curettage and cement filling (n=3), en bloc resection with reconstruction (n=3). Adjuvant alcoholization was used in one case. The histological study searched for an aneurysmal component within the tumor. Four patients were lost to follow-up and 59 patients were analyzed with a mean follow-up of 53 months (range 1–162 months). Statistical tests were applied to the data set to search for factors of risk of recurrence.

Results and discussion: The inaugural syndrome was pain (n=52) or a palpable mass (n=3); the tumor was a fortuitous discovery in one case. Comparison with series including both children and adults revealed certain specific features of this pediatric series. The sex ratio was lower in our series; the distal femur localization, frequent in adults, was rare in children. AT one year, the rate of recurrence was 34% in our series (18/53). Fifteen of the 18 recurrences concerned radiologically active (n=12) or aggressive (n=3) tumors. Recurrence predominated in the tarsal bones (3/3), the proximal humerus (6/14), the proximal femur (5/13) and the proximal tibia (3/14). An aneurysmal component was found in 22% of the recurrent tumors and in 16% of those without recurrence. Statistical tests failed to distinguish any significant correlation with recurrence for age, gender, type of treatment, Springfield grade or localization.

Conclusion: The epidemiological data in this series of pediatric chondroblastoma showed features different from adults. The rate of recurrence was particularly high in this multicentric series (but not statistically significant) for localizations in the tarsal bones or a deep joint (with difficult access such as the shoulder and the hip) or with an aneurysmal component.

Purpose: Partial epiphysiodesis of the growth plate due to physeal aggression is a common problem in paediatric patients. Surgical management requires precise imaging. We recall other imaging techniques currently employed and describe a novel method for studying the characteristic features of epiphysiodesis bridges of the growth plate: 3D-magnetic resonance imaging (3D-MRI).

Material and methods: We analysed retrospectively MRI series of 27 epiphysiodesis bridges in 23 children (ten boys and thirteen girls) aged 11.3 years (range 2.5 – 15). We recorded information concerning the cause of the physeal aggression, the joint involved, the type of bony bridge (Ogden classification), the clinical deformation, and the proposed treatment. The 27 bridges were studied on coronal MRI acquired with echo-gradient and fat suppression sequences. Data were processed with a manual 3D reconstruction program in 15 minutes to precisely define the localisation, the volume, and the morphology of the bony bridge and the active physis.

Results: The epiphysiodeses were caused by trauma (65%), iatrogenic aggression (17%), ischemia-infection (purpura fulminans) (9%), juxta-physeal essential cyst (4.5%), and unknown causes (4.5%). Eighty-seven percent involved a lower limb joint, 75% of which involved the tibia. The surface of the epiphysiodesis bridge covered 20% of the physis. The bridges were peripheral (46.5%), central (46.5%), and linear (7%).

Discussion: It is difficult to determine the position and the 3D relations of an epiphysiodesis bridge in a healthy active physis with imaging techniques such as plain x-rays, scintigraphy, tomography and computed tomography. The 3D-MRI method described here provides a sure way to distinguish the active growth plate which gives a high intensity signal and the epiphyseal bridge which gives a low intensity signal. Morphological (size, form) and topographic characteristics of the bony bridge and the physis can be described with precision facilitating therapeutic decision making and guiding surgery. The lack of radiation risk is also an advantage of MRI.

Conclusion: The quality of the images obtained, the safety of MRI and the easy interpretation of 3D reconstructions makes this imaging technique an excellent method for pre-therapeutic analysis of epiphysiodesis bridges.

Purpose: Treatment of femoral epiphysiolysis with major displacement remains a controversial subject. Open repositioning of the epiphysis via a lateral approach as proposed by Dunn allows nearly anatomic restitution but with a high rate of complications. We report our experience with open repositions via an anterior approach which has been more reliable in our hands.

Material and methods: During the last decade, we operated nine hips for epiphysiolysis with major displacement, using the anterior approach to spare the medial circumflex artery. External reduction was not attempted. Preoperative and residual displacement were evaluated using the Southwick technique and according to the position of the femoral head in relation to the Klein line. Early after surgery, a bone scintigram was obtained for all hips. We followed these patients to bone maturity, with a mean follow-up of four years.

Results: The early postoperative scintigrams did not reveal any case of insufficient uptake in the femoral head. Mean correction was 43° on the lateral view, with a mean preoperative displacement of 72°. Mean residual displacement after surgery was 23°. After repositioning, position of the epiphysis in relation to the Klein line was not significantly different from the position observed on the healthy side. Postoperatively, leg length discrepancy was 1 cm. At last follow-up, there have been no signs of osteonecrosis, chondrolysis or osteoarthritic degeneration. At mean 44 months follow-up, all of the patients have unlimited activities, including sports. Only one patient complained of mild climate-related pain.

Discussion: Compared with the lateral approach with trochanterotomy as proposed by Dunn, we have found the anterior approach technically easier and more reliable in terms of protecting the epiphyseal blood supply. The correction obtained, voluntarily preserving a certain degree of under-correction, associated with resection of a portion of the neck enables repositioning without risking vessel stress. Use of a stable internal fixation which allows early mobilisation would be an explanation of the absence of postoperative chondrolysis.

Conclusion: These results appear to be sufficiently encouraging to advocate this technique previously described by PH Martin in 1948.

Purpose: Management of supracondylar fractures of the humerus becomes a controversial issue when there is major displacement. The risk of vessel and nerve injury is very high, making reduction and fixation particularly difficult.

Material and methods: We conducted a retrospective analysis of 100 supracondylar fractures managed over a ten year period. All of these fractures were in extension and exhibited a bone gap. We analysed early and late complications.

Results and discussion: Mean age at trauma was 6.5 years, with six boys for four girls. The left side was involved in 69% of the cases. Falls were the predominant cause (48%).

Thirty-two percent of fractures were complicated initially: nerve injury (n=17), vascular injury (n=12) (including three cases with nerve and vascular injury), open fractures (n=7). The medial nerve was injured in most cases (n=12). Ulnar palsy was noted in four patients and radial palsy in one. Vessel injury led to abolition of the radial pulse in eight patients and the ulnar pulse in one; all resolved after reduction. Ischaemia of the hand was noted in two cases before reduction of the fracture but vascular surgery was not required.

Most of the fixations were achieved with cross pinning (percutaneous insertion in 47 patients and open surgery in 13). Despite minimal medial skin incision, ulnar nerve deficiency was observed after surgery in seven cases; four were rapidly regressive and three required surgical exploration with neurolysis. Six revision procedures were required for secondary displacement (10%).

The 26 Judet fixations led to ten secondary displacements requiring surgical revision for cross pinning. Four cases of postoperative ulnar nerve deficiency were noted: reoperation to release the nerve pinched in the fracture was required for only one patient.

The Blount technique was used in nine cases with four secondary displacements, including one related to two sites of nerve impingement.

Five cases of superficial pin tract infection which resolved rapidly and two cases of deep infection were noted in the early postoperative period.

Formation of a varus ulnar callus was noted in five cases: two required secondary surgery for correction.

Conclusion: Our results point out the high rate of vessel and nerve complications related to these supracondylar fractures of the humerus with displacement. We recommend cross pinning which is mechanically superior and which does not compromise the neurological result if a minimal medial incision is used.

The initial treatment of the congenital clubfoot is still a debated subject among different schools. We report our current experience with Ponseti method.

Materials and Methods: From April 1999 to May 2001 we have consecutively treated with this method 80 idiopathic clubfeet of 57 children put under treatment at neo-natal period. Progressive correction of the deformity has been obtained with 7 toe-to-groin plaster casts changed weekly. When complete derotation of the hind-foot and forefoot has been reached, subcutaneus tenotomy of the tendon Achilles has been performed. At the end of this first period, the feet have been adapted in Denis Browne splint, worn full time for four months and thereafter just at night. The feet have been evaluated clinically (score of Dimeglio and Bensahel), radiologically and some with MRI.

Results: Whole correction of the deformity at the end of treatment with plaster casts, has been achieved for 71 times. When the plaster casts are removed, the talocalcaneal divergence, on antero-posterior and lateral views and the tibial-calcaneal angle (x-ray in maximum dorsal flexion ), were respectively, as an average of 20; 30,7; 21,9 degrees. At an average of 20 months follow up, 54 feet of 80 had a score of 0 or 1 of 20, and 14 had a score of 2; on radiological aspect the talo-calcaneal divergence in antero-posterior and lateral views and the tibial-calcaneal angle were respectively as an average of 29; 24,5; 14 degrees. At this evaluation the percentage of relapses of the deformity was 20% (17 cases). All the relapses have been treated again in plaster casts with 40% of success. So far, only four medial release operations have been necessary. Six feet benefited by the transfer of the tibialis anterior tendon to the third cuneiform and slight medial release.

Discussion and Conclusion: The Ponseti’s method presents several advantages: high quality reduction of the clubfoot with the restoration of a “sub-normal” anatomy, low cost and small displeasing worry for the parents, with this method the functional re-education does not seem to improve the quality of results. The prevention of the relapse goes by good compliance to the splint.