Purpose of the study: Appropriate surgical treatment for severe lumbosacral spondylolisthesis remains a subject of controversy. Correction of the anterior displacement of L5 and the lumbosacral kyphosis is considered dangerous because of the risk of neurological complications. We present a consecutive series of 40 patients who were treated with the Padovani double plate method for high-grade spondylolisthesis. The long-term outcome was assessed. The reasons for abandoning this method were also discussed.

Material and methods The files of 40 patients (15 boys and 25 girls, aged 8–20 years) underwent surgery in our center from 1979 to 1996. All presented anterior displacement of L5 greater than 50%. After release of the L5 and S1 roots via a posterior approach and insertion posteriorly to anteriorly of two anchors in the S1 body, correction of the L5 displacement was achieved via a transperitoneal anterior approach using a plate applied to the anterior surface of L5 and progressively bolted to the S1 anchors. Clinical and radiological outcome was assessed. Spineview was used for angle measurements. The Beaujon and Japanese Ortopaedic Association scores were used for the clinical assessment.

Results: Lumbosacral fusion was achieved in all patients with complete correction of the L5 displacement in 38. A postoperative radicular deficit was noted in twelve patients and resolved completely in ten. Six patients experienced progressive destabilization of the L4–L5 level. Deep infections in contact with implanted material were noted in five patients. At 18 years mean follow-up, 35 patients are symptom free.

Discussion: This technique enables excellent correction of the L5 displacement and an excellent rate of fusion. The method is particularly challenging technically and the rate of complications is high. Reduction of the displacement appears to be associated with numerous radicular deficits, even after prior release. The plate which was rather large for the youngest patients led to lesions of the L4–L5 disc and destabilization of the suprajacent levels.

Conclusion: Although this technique enables optimal and definitive correction of the lumbosacral deformation, the high rate of complications has led us to change our strategy for the treatment of high-grade lumbosacral spondylolisthesis.

Introduction: Carpal tunnel syndrome is frequent in children with mucopolysaccharidosis. Diagnosis is difficult according to the slow progression of compression of the medial nerve and treatment is controversial.

Material & Methods: Twelve children were studied: 8 Hurler’s, 2 Hunter’s and 2 Maroteaux-Lamy’s diseases. All had clinical and EMG evaluation. Eight of them were operated, both sides.

Results: All the children had progressive and severe hypoesthesia before surgery. Nerve conduction velocity was very slow compared to normal values. After the open surgical release (16 cases) and synovectomy of flexor tendons (13 of 16 cases), all the patients were improved. The histology of the synovitis showed less glycosaminoglycans in patients who had a bone marrow transplantation. Surgical treatment must be an open release of the anterior ligament associated with a synovectomy of flexor tendons and a ventral epineurotomy

Discussion: According to the literature, carpal tunnel syndrome is observed in two third of patients of type I, II and VI mucopolysaccharidosis. Diagnosis is often difficult when cervical compression of the spinal cord is an associated factor. The diagnosis is made with clinical and EMG evaluation. Treatment must be early. MRI is an alternative to evaluate the morphology of the nerve: its compression below the carpal ligament and its bulky aspect just proximal to the carpal tunnel are clearly shown.

Purpose of the study: Congenital pseudarthrosis of the clavicle is rare, only 200 cases having been reported. Based on 25 personal cases and an overview of the literature, we try to explain the etiology of this condition and the different kinds of treatment.

Material and methods: A retrospective analysis was performed on twenty-five children (16 females, 9 males, mean age at the end of the follow up – 11.5 yrs) from three different centers. We assessed the outcome of surgical and nonsurgical procedures, based on pain, functional ability, cosmetic results, and x-ray examination.

Results: A family background was noted in three children. The lesion always involved the right side. Twenty patients presented a bump over the middle third of the clavicle, thirteen a foreshortened shoulder girdle, three complained of discomfort. In two cases, palpation of the clavicular area was painful. No neurovascular compressive syndrome was reported. None of the patients complained of a decrease in the range of motion or in the strength of the upper limb. X-rays showed a middle third defect. In five cases we found abnormal first ribs.

Seventeen patients underwent surgery, at a mean age of 6 years and 4 months. The procedure always included excision of the pseudarthrosis at both ends and internal fixation with a wire or a plate. In only eight cases a bone graft was used. Healing was achieved in fourteen patients. Three patients needed a second surgical procedure. In these 3 cases we had not used bone grafting. All patients had a normal range of shoulder motion, except a twelve year old girl who complained of discomfort of the right upper limb. The cosmetic result was good in eleven cases, one surgical wound was noted as hypertrophic, and one developed a keloid. An asymmetry of the trunk was still noted in seven cases. The x-rays showed symmetric clavicles in ten cases.

Eight patients were treated conservatively. All of them had a normal range of motion of the shoulder, six had a good cosmetic result and two cases a poor one.

Discussion

According to Alldred, the anomaly results from the failed coalescence of the two primary ossification centers of the clavicle. The overview of the literature and our findings (in one case) confirm that the cartilage which covers both ends of the bone is made of growth cartilage. However, the true mechanism of the nonunion is still unknown. The three familial cases of our work suggest a possible genetic transmission of the disease.

The diagnosis is based on the following criteria: right side lesion, found in infancy, without previous fracture, increasing size with growth, without major functional consequences, without neurofibromatosis or cleidocranial dysostosis symptom. X-rays or histologic examination will confirm the diagnosis showing the usual findings described above.

Complications of the pseudarthrosis of the clavicle are rare and late. Conservative management appears to give good results as seen with our eight patients. However surgical treatment ensures symmetrical shoulder girdles and good function with few complications. Therefore, we recommend performing an excision of the cartilaginous caps, followed by an iliac bone graft and an internal fixation with wire. Surgical management will be preferred in symptomatic patients, in the case of major or increasing deformity, or on parental request.