Since 1976 we have performed 60 radioactive synoviorthesis in 53 haemophilic patients with age from 6 to 40 years with a mean of 10 years of age, 45 of these patients were under 12 years of age. The knees were injected in 38 cases, elbow in 16 cases, ankles in 5 and shoulders in 1 case. The procedure was performed in 6 sittings of 10 patients each. The synoviorthesis is done by an intrarticular injection of the radioactive material preceded by a local anesthetic. The clinical results of this procedure gives an 80 % of excellent results with no further bleeding. One of the criticisms against this method is the possible chromosomal damage induced by the radioactive material. In our center, two previous studied have been done in order to see whether these possible changes are everlasting and both have demonstrated that chromosomal changes are reversible. The radioactive material used in these synoviorthesis was 189 Au In 1978, 354 metaphases were studied with 61 ruptures, 17.23 %, (non premalign) and 6 structural changes -considered premalignant, 1.69 %. Any number below 2 % is considered non dangerous. A further study was done in 1982, in the same group of patients with a result of 21 ruptures, 3.34% and no structural changes. This demonstrated that the possible premalignant changes disappeared with time. A third study was performed in a series of 13 patients that unstained radioactive synoviorthesis with Re 186 in November 1991. We performed for comparison a chromosomal study just before and 6 months after the radioactive material injection. The results confirmed that changes that could be attributed to the radiation, appears equally in non irradiated patients and those due to the radiation disappear with time, never reaching the dangerous zone of 2 %. In these group treated with 186 Re we studied an additional number of 130 metaphases with identical results and NO structural changes.

Conclusions: In view of these results, it seems that radioactive synovectomy is safe procedure and gives great benefits to the haemophilic patients, and no long standing structural chromosomal damage

Introduction: Arthrodesis of the wrist must still be considered as a useful procedure in the treatment of certain deformities of the wrist joint that by performing this operation can improve the function or the aesthetics of the limb. Except those techniques of partial carpal arthrodesis, the surgical procedures of wrist arthrodesis requires a bridging from the radius to the metacarpal in order to stabilize the joint. When this procedure is performed in a growing child this can be a draw back.

Material: We have developed a new procedure that producing the arthrodesis distally to the growing cartilage of the radius does not interfere with the growing at wrist level. Furthermore, the use of a wire shroud gives an active fixation reducing postoperative immobilisation and shortening healing time. Since 1986 we have performed this technique in 9 cases of children with mean age of 14 years. The pathology was in 5 cases Cerebral Palsy, in 2 cases Juvenile Rheumatoid Arthritis and in 2 cases Obstetrical Brachial Plexus Palsy. Eight cases were males and 3 cases females. The indication for surgery was flexion deformity of the wrist in 8 cases and extension in 1 case. Four cases had carpal instability (including the 2 Juvenile Rheumatoid Arthritis).

Results: The time of fusion was in all cases 2 months with primary arthrodesis and improved extremity. Functional improvement seemed to be most related to pre-operative conditions. Follow up ranged from 4 years to 6 years.

Conclusions: The good results obtained with this procedure encourage us to present this new surgical technique to be applied in the still growing child.

Europeam Group of Neuro-orthopaedic (GLAENeO), Caracas, The prevention of a dislocated hip is one of the aims of early surgery in Cerebral Palsy children, specially those severely involved. We performed a retrospective study of those cerebral palsy patients operated of adductor tenotomy between 1975 and 1995 with a total of 1474 patients. We grouped them in those who had a unilateral tenotomy and those who had a bilateral tenotomy as primary surgery. Of these only 8% had an obturator neurectomy, without walking ability, and 92 % had it not. Age at surgery varied from 6 months to 8 years of age with a mean of 4 years and 3 months. Group I: 792 patients (53.7 %) with unilateral adductor contracture, sustained a unilateral adductor tenotomy. Of these patients a total of 619 (78, 2 %) required a contralateral adductor tenotomy at a mean of 3 years and 6 months. Group II: 682 patients (46, 3 %) with bilateral adductor contracture that had a bilateral adductor tenotomy in one stage. Of the 792 patients that sustained a two stage adductor tenotomy, 123 (20%) presented a unilateral dislocated hip and of these 115 (93 %) occurred in the hip operated secondly at a mean of 1 year post tenotomy. Of the 682 patients with bilateral adductor tenotomies only 7 (1 %) had a dislocated hip 2 years post tenotomy. Of the 72 dislocated hips, 12 (59 %) were quadriplegics, 28 (22 %) were diplegic, 21 (18 %) hemiplegics and 1 (1 %) tetraplegic.

Of the 619 patients tenotomized in two stages, in 143 the diaphyseal – cervical angle was 155 ° (23,1 %), at a mean of 6 and a half years of age and 3 years post the second tenotomy. In 102 of these patients (71 %) a varus derotation osteotomy was performed in the hip operated in the second act with further dislocation of the hip in 20 cases (20 %). Of the 685 patients with bilateral tenotomy in one stage, varus derotation osteotomy was required in 68 (68 %) at a mean of 6 years of age with only a 3 % of dislocations in this group.

In view of these results we recommend a bilateral adductor tenotomy be performd regardless of a difference in the degree of contracture of both sides, thus coordinating the forces and avoid further dislocation the hip.

The abnormal shortening of a metatarsal (MT), being congenital or aquired, may cause functional problems, on altering feet support. Besides some deformities may be aestheticaly unacceptable to some patients, particularly females. We performed a retrospective, concurrent epide-miological revision on 28 records of patients that had MT lengthening for a short metatarsal. ( 21 patients with 9 bilateral.) These were the 4th. in 22 oportunities, followed by the 1st in 7, the 3rd. in 2 and the 5th. in 1. Etiology was in 20 cases congenital shortening, 2 shortening after equinus foot surgery and 1 after osteomyelitis. Seven cases had bilateral elongation, thus making 28 cases. Age ranged from 5 years to 20 years, with a mean 10 years. The indications for surgery were pain in 10 cases and aesthetic in 18 . All. were females except one.

The Caracas group used a modified mini Anderson apparatus. After 1992 the apparatus was modified for the last 4 cases for one that could be placed only on the dorsal aspect of foot, thus allowing weight bearing. The application was performed under image intensifier placing the threaded pins perpendicularly to the MTT with transversal diafisis osteotomy, starting the elongation between 5th and 10th day at a speed of 1.5 mm weekly at a range of 0.5 mm every second day, in a period from 3 weeks to 8 weeks with a mean of 5.5 weeks. Ten had unilateral lengthening (83.33) and 2 bilateraly (16.57%) making a total of 14 metatarsal lengthenings. All were females and all had elongation fix-ation callotaxis according to DeBastiani. The cases were operated from 1987 to 1994 and with more than 6 years follow up. Age ranged from 10 to 15 years in 10 cases and 16 to 20 in 2 patients. The MTT mostly involved was the 4th. in 12 patients (85.71%), 2 bilateral (14 MTT), and the 3rd in 2 cases (14.29%), . The shortest MTT lengthened measured 3.5 cmts. Lengthening obtained ranged from 5 mm. to 22 mm, with a mean of 14.3 mm. One patient obtained 5 mm. (7.14%), another 10 mm. (7.14%), one 11 (7.14%) and 1 15mm. (7.14%), 5 (35,71%) from 16mm. To 20 mm. and other 5 (35.71%) from 21mm. to 25mm.

Complications were pseudoarthrosis in 3 cases, delayed union in 1 case and angulation in 1. These were treated by reintervention and bone graft maintaining the lengthening in 4 and in the other, 1 pseudoarthrosis the lengthening was lost.

The Buenos Aires Group with 16 lengthenings in 11 patients,used an external apparatus with 2,3 or 4 joints and threded 1 mm pins fixed in the metatarsal to length, dorsally. . In some cases the proximal pin was fixed to third cuneiform and in 6 to the the distal in the proximal phalang to aviod bending. This last mentioned method were not used afterwards because correct alignment was obtained fixing the apparatus only in the metatarsal. The corticotomy was metaphysoepyphisary lenghthening 0.5 mm daily starting the 8th day. Hospitalization time ranged 2.5 days. Minimal follow up was 2.6 years. Nine of 11 cases recovered the normal metatarsal formula. Pain disappeared in cases that had it previously but aesthetic requirements were not always completely fulfilled, special with the 1st. MT. Mean elongation length was 17 mm. Mean percentage ogf elongation was 40%. Mean duration of total treatment was 112 days, making mean healing time index of 65 days per every centimeter elongated. No axial deviation ocurred. All cases healed at callus site. The case of osteomyelitis had bone graft at operation. Complications were 3 superficial infections at pin site and 1 case of recurrent deep infection. An elongation above 50% of original length of MT should be avoided.