Purpose of the study: Among the causes of secondary congenital equinovarus club foot, neurological disorders predominate. The entity we examine here corresponds to irreversible pure motor paralysis with no sensorial disorder affecting the lateral compartment predominantly and sometimes associated with involvement of the anterior compartment. There is no literature on this entity. Beyond the question of the aetiology, the demonstration of this pathological condition can modify therapeutic strategy in order to prevent recurrence.

Material and methods: We examined 42 congenital equinovarus club feet with persistent pure motor paralysis involving the lateral compartment and sometimes the anterior compartment with a mean 10 years follow-up. The Dimeglio classification was used and an analytical muscle score was noted for each patient. Complementary tests included an electromyogramme when possible. Conservative treatment was the rule either using a functional method or the Ponseti method; surgery was then proposed when necessary for posteromedial release with or without palliative muscle transfer. The following procedures were performed: posteromedial release (n=33) and muscle transfer (n=26): tibialis posterior (n=22), tibialis anterior (n=3); hemisoleus (,n=1); tibialis posterior associated with flexor digitorum longus (n=3).

Results: Conservative treatment was used for all feet but all presented recurrence and required secondary surgery (33 posteromedial releases and 26 muscle transfers).

Discussion: This study opens the discussion on the similarity between idiopathic and arthrogryoposis club foot since the electromyography sometimes reveals an anomaly of the anterior horn. Thus club foot with pure motor and persistent paralysis involving the lateral and/or anterior compartment will not respond sufficiently to nocturnal contention if an adapted muscle transfer is not associated.

Conclusion: Muscle transfer to reactivate dorsal flexion of the foot enables a better functional outcome. First intention conservative treatment can be instituted while waiting for potential recovery. If the paralysis persists beyond one year, muscle transfer is indicated before the deformity recurs and requires an associated posteromedial release.

Purpose of the study: the Pavlik harness has been used for the treatment of congenital hip dislocation since it was designed by Arnold Pavlik in 1950. There remains however a certain debate concerning the best moment to start treatment and its duration. We advocate early use of the Pavlic harness for a short period.

Material and methods: Forty-five hips (34 infants) were treated. The diagnosis of dislocation was clinical. The Barlow and Ortolani maneuvers were used to search for clinical instability classed as «positive dislocation test» or «negative test but presence of piston movement». Different classifications of positive tests were used to search for an association with increasing severity of hip instability. Static and dynamic ultrasound was then used to confirm the diagnosis of hip dislocation. A Pavlik harness was installed immediately after diagnosis of congenital hip dislocation, on the day of birth if possible, according to the precepts proposed by the inventor.

Results: Among the 43 hips analyzed I the present series, reduction and stabilization was successfully achieved with the Pavlic harness in 40 used as early as possible for a short a period as possible. This 95.6% success rate (2 failures, 0 complications) was achieved within 3 o 8 weeks.

Discussion: Our results are comparable with other series reporting early use of the Mubarak method. The duration of treatment was shorter with our therapeutic method. We did not attempt to treat the dysplasia, spontaneous regression was monitored radiographically.

Conclusion: We consider congenital hip displasia to be a therapeutic emergency. Treatment should be undertaken as soon as the dislocating intrauterine constraints cease. Early use of the Pavlik harness on easily dislocated or dislocated reducible hips has given excellent results. The shorter treatment duration does not lead to any recurrence as long as clinical stability with formal radiographic confirmation at treatment end.

Purpose: The purpose of this work was to demonstrate the usefulness of osteoplasty block for the treatment of primary hip osteochondritis.

Material and methods: Eighteen children underwent surgery between 1992 and 2001. Mean age at diagnosis was eight years five months (5–13 years). Preoperatively, mean motion limitation was −25 in abduction and internal rotation. Radiologically the series included: Catterall II Herring B with signs of high-risk head (n=2), III B (n=7), III C (n=1), IV B (n=1), IV C (n=2), and sequelar stage (n=2). Mean excentration was 6.5 mm and mean lateral overhang was 10.2 mm. Surgery was indicated because of an aggravation of the excentration with revascularisation. An iliac graft was encrusted in a limbic rail and covered with rectus femoris tendon left continuous to provide elastic support. A bermuda cast was used for 17 children with immediate weight bearing for eleven. Hospital stay was 36 hours for all children.

Results: Sixteen children were reviewed at mean follow-up of three years two months. There were no complications. Clinically, there all patients were pain free, but three developed persistent limping. Ten had a moderate limitation of hip movement and three had severe joint stiffness. Radiologically, there was good head coverage in fifteen hips and joint congruency in fifteen, including eleven with concentric congruency. The intervention was considered useful for twelve children, and not useful for one who developed complete lysis of a poorly positioned graft. Usefulness was uncertain for three children, including the two with a sequelar-stage hip at diagnosis.

Discussion: Femoral osteotomy to correct the valgus and pelvic osteotomy to reorient or widen the acetabulum are effective treatments but have many disadvantages (limited abduction movement, leg length discrepancy, re-intervention to remove material). The excellent integration of the plasty block at mid term is a sign of effective head-acetabulum adaptation. Clinical and radiological results have been similar to those obtained with other methods. Joint stiffness and postoperative limping are observed in very severe cases. Joint prognosis depends on the severity of the disease.

Conclusion: This series of paediatric patients who have not yet reached bone maturity shows that the plasty block meets expectations for the treatment of early-stage primary hip osteochondritis. Treatment time is short and there are no complications.

Purpose: Physeal distraction can be used for the treatment of the consequences of epiphysiodesis bridges, correcting simultaneously angular deformations and length discrepancy.

Material and methods: Chondrodiastasis was performed in six children aged 13.1 years (range 10.4–15.7). The cause of the epiphysiodesis was trauma in three children (2 distal tibia, 1 distal radius), osteomyelitis in two (distal femur), and surgical sequela of a clubfoot (distal tibia). Mean follow-up was two years (18 months – 4 years). An Ilizarov device was used in four cases and an Orthofix in two.

Results: Limb length discrepancy was corrected in all cases. Angular correction was insufficient in two. Distraction was continued for four months (1–9) and total duration of treatment was 7.5 months (4–13). Minor complications were pin track infection (n=2) and joint stiffness (n=3). Major complications were one fracture of the femur on a pin site and premature closure of the growth cartilage treated by callotasis and one fracture after removal of the external fixator, treated by plaster cast immobilisation. The final outcome was good in both of these children.

Discussion: De-epiphysiodesis with surgical resection of the bony bridge can only be performed before a certain age (10–11 years) and the outcome in uncertain. The principle advantages of physeal distraction applied for angular deformation in growing patients is that it avoids the need for osteotomy and allows progressive correction. This noninvasive method allows angular correction in the upright patient, concomitant lengthening is also achieved. Chondrodiastasis makes an exact correction of the deformation without resection of the bony bride which can be ruptured by simple distraction. The fertility of the growth cartilage after distraction must be considered as lost so the amount of correction must be calculated on the basis of a complete and definitive postoperative epiphysiodesis.

Conclusion: Chondrodiastasis allows correction of acquired and predictable epiphysiodesis bridges at the apex of the deformation and without direct access. This method can be used for partial epiphysiodesis (less than 50%) in children who have not reached maturity. After distraction, the growth cartilage must be considered as definitively closed.