Purpose of the study: Assessment of limb reconstruction results using vascularized fibular grafts after bony resection for malignant tumors in children.

Material and methods: Thirty children (9 girls and 21 boys)underwent surgery between 1993 and 2000. Mean age was 11 years. Tumor localizations were: femur (n=17), tibia (n=6), humerus (n=5), radius (n=1) and distal ulna (n=1). Mean length of bone resection was 16 cm (range 10–26 cm). For 22 children, the adjacent epiphysis was preserved. For the eight others, fusion was also performed. Two surgical teams operated sequentially: the first team performed the tumor resection and the second (an orthopedist for the osteosynthesis and a plastician for the vascularized fibular transfer) the limb reconstruction. Radiographic and clinical assessment was completed with bone scintigraphy. The index of graft hypertrophy was determined with the De Boer and Wood method. Functional outcome was assessed with Enneking criteria.

Results: Mean follow-up was 51 months (range 2 – 9 years). Early amputation was necessary for two children due to local oncological complications. One patient died of pulmonary metastasis eight months after limb reconstruction. Among the 27 other patients, primary healing was achieved in 22. In the five with primary nonunion, bone scintigraphy showed objective signs of a lack of blood supply to the graft. Secondary union was achieved with a complementary autologous bone graft in four cases. All cases of stress fracture healed with orthopedic treatment. For the 22 patients with primary union, the graft hypetrophy was 22–190% (mean 61%). For the five patients without bone vascularization on the scintigraphy, the fibular graft failed to hypertrophy. Functional outcome was satisfactory. The modified Enneking score (30 point scale) was 26 (range 19–30 points).

Discussion: Limb reconstruction results are directly related to good patency of vascular anastomoses. Postoperative bone scintigraphy is useful to determine blood supply to the graft and to establish the final prognosis. In the case of vascular failure, an autologous bone graft can be proposed early to enable union. Close collaboration between the plastic surgery and the orthopedic team is the key to successful limb reconstruction with a vascularized fibular graft.

Purpose of the study: In spina bifida, independently of limb paralysis, spinal deformation can cause significant static disorders (scoliosis, kyphosis, or hyperlordosis) which in turn cause significant disability. These deformations generally develop during growth. We wanted to determine the predictive value of a clinical classification based on the neurological examination at five years for risk of spinal deformation.

Material: This retrospective study included 163 patients. Groups were defined on the basis of motor function determined by the neurological examination at five years: group I: L5 or below (all patients in this group had motor deficit leaving at least one L5 segment intact); group II: L3–L4; group III: L1–L2; group IV: T12 and above.

Results: Results showed that group I was a factor predictive of an absence of future spinal deformation. Groups III and IV were predictive of presence of a future spinal deformation. Group IV was predictive of future kyphosis.

Discussion: It is well known that the higher the neurological lesion in spina bifida, the higher the rate of spinal deformation. No work has however set the limits nor provided predictive rules useful in clinical practice. Our work demonstrated that this classification based on the motor function established by neurological examination at five years can predict which children have a risk of developing a spinal deformation and thus enabling early detection and treatment.

Conclusion: This neurological classification can be used as a clinical tool for the prognostic evaluation of spina bifida.

Purpose: The purpose of this work was to present the long-term outcome after resection of thoraco-lumbar, lumbar, or lumbosacral hemivertebrae in 69 children.

Material and methods: Sixty-nine children (35 girls and 34 boys) underwent surgery at a mean age of 3 years (range 1 year – 10 years 6 months). Mean follow-up was 6 years (range 6 months – 18 years). Resections involved thoracolumbar (n=20), lumbar (n=34), and lumbosacral (n=15) hemivertebrae. Congenital vertebral and visceral malformations were present in 32% and 41% of the children respectively. Ten patients had an underlying neurological malformation.

A single operation was performed in 60 patients using a combined anterior and posterior approach and convex posterior CD baby instrumentation. Nine patients underwent two operations one week apart. All patients wore a corset brace for six months.

Results: Structure curvature: the mean Cobb angle was 35° preoperatively, 16° postoperatively, and 15° at last follow-up.

Compensating curvature: the mean Cobbe angle was 21° preoperatively and 12° at last follow-up. Complications: partial deficit of the anterior tibialis (n=1), nonunion (n=3), infection (n=1), disassembly (n=3), valgum tibia at the site of the fibular graft harvesting (n=1).

Discussion: At these spinal levels, hemivertebral resection appears to be the most appropriate technique for children aged less than three years as long as there are no clear signs of progressive curvature.

Purpose: We performed a biometric evaluation of the femoral trochlea in the human foetus and compared measurements with those observed in the adult in order to search for correlations with other biometric parameters of the human femur.

Material: Twenty-two foetuses with no orthopaedic anomalies were preserved in formol. The 44 knees were studied. Fœtal age varied from 26 to 40 weeks.

Method: After anatomic dissection, digital photographic documents were analysed using angular measurement software. The following dimensions were measured on the distal epiphysis: anteroposterior thickness of the condyles, protrusions of the lateral and medial trochleal edges, the difference in condyle height, the trochlear opening angle alpha, trochlear slope. Femoral anteversion, length of the femoral neck, and the neck-shaft angle were measured on the AP view of the femur.

Spearman’s test was used to search for correlations. Results were compared with those measured under the same conditions in a series of 32 adult knees published by Wanner.

Results: The alpha angle of trochlear opening was 148° with a coefficient of variability of 4%. The alpha angle was greater than 150° in 18 trochleae. The lateral edge of the trochlea was higher than the medial edge in 37/44 trochleae. There was no correlation by age and sex.

The femoral measurements showed 27.01° anteversion with very wide variability (coefficient 46%) and no correlation with trochlear opening.

No significant differences were observed between the fœtal and adult measurements.

Discussion: Our data are the first reporting anatomic measurements of the fœtal trochlea. The morphology of the lower extremity of the femur during the third trimester of pregnancy is globally the same as in adult femurs. Morphological changes of the proximal femur occurring during growth do not appear to modify the morphology of the distal femur. The deep and asymmetrical engagement of the patella onto the trochlea is a characteristic of modern man and is considered to be a consequence of bipedal stance. Our study would appear to confirm that the anatomic characteristics of the human trochlea have been integrated into the genome in the course of evolution. This suggests that a genetic origin of trochlea dysplasia, as suggested by Dejour, is a reasonable hypothesis.

Purpose: Reconstruction after resection of malignant bone tumours remains a major challenge. Free vascularised fibular grafts may be a useful alternative in this indication.

Material: Thirty children (nine girls, twenty-one boys) were treated between 1993 and 2000. Mean age was eleven years. Tumour histology was: osteogenic osteo-sarcoma (n=20), Ewing tumour (n=5), justacortical osteosarcoma (n=3), synovialosarcoma (n=1), and chondrosarcoma (n=1). Tumours were located in the femur (n=17), the tibia (n=6), the humerus (n=5), the radius (n=1), and the distal fibular (n=1). The length of resection varied from 100 mm to 260 mm (mean 160 mm). Internal fixation was used in 27 cases and external fixation in three. The adjacent epiphysis was preserved in 22 cases and initial arthrodesis was performed in eight.

Method: Patients were followed clinically and radiographically. A bone scintigram was obtained in all patients at least once during the postoperative period. Radiological assessment was based on the hypertrophy index of the graft using the method described by DeBoer and Wood. Functional outcome was assessed using the Enneking criteria.

Results: Mean follow-up was 51 months (range 2 – 9 years). Early amputation was required in two patients due to local ocological complications. One patient died at eight months follow-up due to lung metastasis. Among the remaining 27 patients, primary bone healing was achieved in 22. The five other patients exhibited clear signs of non-vascularisation. Successful healing was achieved in four of these patients after a complementary autologous graft. All cases of stress fracture healed after simple immobilisation.

The twenty-two patients who achieved primary bone healing developed a hypertrophic graft (mean 61%, range 22 – 190%). Graft hypertrophy was not observed in the five cases requiring a secondary graft after the scintigram demonstrated lack of vascularisation. Hypertrophy of the vascularised fibular graft was more marked for lower limb reconstructions than for upper limb reconstructions..

Functional outcome was satisfactory in all cases. On the 30-point Enneking scale as modified, our patients achieved a mean 26 points (range 19 – 30).

Discussion: Outcome was directly related to patency of the vascular anastomoses. Bone scintigraphy, performed one month after reconstruction surgery, was an important element for assessing prognosis. In case of unsuccessful vascularisation, a complementary cortico-cancellous graft should be used. Early weight-bearing is advisable using adequate protective devices. Dynamic osteosynthesis systems should be helpful in improving graft hypertrophy.