Aim

Extraspinal osteoarticular tuberculosis (TOA-ER) is a rare form of extra-pulmonary tuberculosis. It remains a topical problem not only in underdeveloped countries but also in developed countries due to cases of immune deficiency. Through a study of 40 cases, we specify the current diagnostic aspects of TOA-ER and detail their therapeutic and evolutionary modalities.

Introduction

Sternoclavicular dislocations are well-known adult injuries. The same traumatism causes growth-plate fracture of the medial clavicle in children and young adults. At this location, the emergence of the secondary ossification center and its bony fusion are late. We report the results of 20 cases hospitalized in the Toulouse University Hospital Center that were treated surgically.

Purpose of the study: Duplication of the thumb is the most common congenital anomaly of the first ray. The characteristic feature of type IV is the diversity of the clinical forms and the presence of certain complex forms particularly difficult to treat (Hung IVD). We propose a new procedure for reconstruction of IVD type thumb duplication.

Material and method: This new procedure was used for thumb reconstruction in two boys with type IVD thumb duplication. Mean age at surgery was 10 months. Surgical technique. The future incisions were traced with a central skin resection removing the most hypoplastic nail entirely (generally the radial nail). At the bone level, a longitudinal osteotomy of the proximal phalanges was made over the entire length to remove the central part and obtain a width for the first phalanx comparable to that of the contralateral thumb. An oblique osteotomy was cut in the base of the distal phalanx of the ulnar hemithumb with resection of a radial corner. The same type of osteotomy was performed at the base of the distal phalanx of the radial hemithumb, but with preservation of the radial corner and resection of the rest of the radial thumb. The proximal hemiphalanges were sutured as were the bases of the distal phalanges. This produced automatic realignment and stabilisation of the interphalangeal joint without an ungueal intervention.

Results: The three children were reviewed at 24, 18 and 12 months. The Horii score was good in all cases.

Discussion: Type IVD duplications of the thumb are difficult to treat and may leave serious sequelae. Our technique is based on the principle of a central resection of the proximal phalanges associated with partial resection of the base of the distal phalanges. This enables realignment and stabilisation of the interphalangeal joint while avoiding the problem of ungueal dystrophy since only one nail is preserved. Our preliminary results are encouraging but must be confirmed with a longer term study.

Purpose of the study: For symptomatic discoid meniscus, the treatment of choice in children is arthroscopic meniscoplasty. The treatment of associated meniscal lesions remains a subject of debate. The purpose of our work was to evaluate our results with arthroscopic meniscoplasty associated with meniscal repair as needed and the findings of the systematic postoperative MRI.

Material and methods: This was a retrospective series of patients treated by one operator. There were 23 discoid menisci (21 patients) treated from 2004 to 2007 with arthroscopic meniscoplasty followed by a complementary procedure depending on the residual meniscus: abstention if there was no associated lesion, suture or reinsertion for reparable lesions, partial meniscectomy for non-reparable lesions. The Lysholm and Tegner scores, plain x-rays, and MRI were obtained systematically.

Results: Mean age at surgery was 9.8 years. The Watanabe classification was I:9, II:9, III:5. Arthroscopy revealed 15 lesions, including 11 longitudinal tears. Meniscoplasty was performed in 9 cases alone, associated with partial meniscectomy in 6 and with repair in 8 (5 cases of disinsertion and 3 tears). Mean follow-up was 37.1 months. The mean postoperative Lysholm was 87.9, the Tegner 5.9. Outcome was considered satisfactory or very satisfactory by 90% of patients. MRI failed to reveal any signs of chondral degeneration or meniscal tear. There were however four cases of high intensity intra-meniscal signals and one meniscal cyst. Mean measurements of the residual meniscus were: anterior segment 8.6 mm thickness and 2.6 mm height; middle segment 5.5 and 2.3 mm; posterior segment 5.8 and 3.0 mm. One case of osteochondritis of the lateral condyle was noted postoperatively.

Discussion: To our knowledge, there is no other study evaluating the outcome of discoid meniscus surgery with postoperative MRI. There have been few reports concerning meniscoplasty then repair. This approach spares meniscal tissue, essential for children. We obtained good clinical results and patient satisfaction. At the MRI, the residual meniscus had a morphology close to normal. There were no signs of tears. The high intensity signals occurred in patients with good outcome.

Conclusion: Arthroscopic meniscoplasty associated with repair or partial meniscectomy as needed appears to be a good therapeutic solution for discoid meniscus in children.

Purpose of the study: Surgical strategies for high-grade spondylolisthesis are controversial. The main subject of debate concerns the indications for reduction or in situ fusion. We present mid-term results obtained in a series of patients with high-grade spondylolisthesis treated by posterior reduction and fusion.

Material and methods: Sixteen patient who had undergone surgery for spondylolisthesis of the superior isthmus > 50% were reviewed. Mean age was 12 years (range 9–16 years). Preoperatively, all patients were symptomatic with lumbalgia, truncated radicular pain, and gait anomalies. Surgical treatment consisted in a single posterior approach, L5 laminectomy, curettage of the L5-S1 disc combined with excision of the S1 dome, L4-S1 instrumented reduction, anterior L5-S1 and posterolateral L4S1 arthrodesis. Postoperative immobilization was achieved with a resin lumbar cast with crural stabilization for three months then a lumbar orthesis for three months. Clinical and radiographic outcome was assessed at 44 months on average (range 10–260 months).

Results: Clinically, 14 patients were pain free and had resumed their former activities. One patient complained of intermittent pain. No improvement was observed in one patient. Radiographic results were: displacement 78% (range 52–100%) preoperatively and 30% (8–95%) at last follow-up. The L5S1 displacement angle was 14° kyphosis (range 8–30°) preoperatively and 9° lordosis (range 3–12°) at last follow-up excepting one case with complications. The pelvic incidence was 85° (range 65–100°) preoperatively and 74° (range 50–90°) at last follow-up. Complications: There was one early infection treated by wash-out debridement and antibiotics without removing implants. Disassembly of the implanted material in one patient with a poor clinical result led to complete recurrence and lumbosacral kyphosis. Sacral screw fracture was diagnosed in six patients on average one year after surgery but without any progression or recurrence of the displacement. There were no neurological complications.

Discussion and conclusion: Posterior reduction enables restoration of a good sagittal balance. More than the reduction, it is particularly important to restore the lumbosacral junction in a lordosis position to guarantee long-term stability. This technique is a difficult surgical challenge and raises the risk of recurrence and potential neurological complications.

Introduction: Upper root injuries (C5–C6±C7) account for 75 % of all obstetric brachial plexus palsies (OBPP). Among them, about thirty percent develop a medial contracture of the shoulder due to an imbalance between strong internal rotators and weak external rotators. This causes glenohumeral deformities. To decrease the internal contracture it had been proposed either to release the subscapularis (Sever procedure) or to perform a capsular release (Fairbank procedure). Arthroscopic capsular release was proposed in young patient to reduce the medial contracture.

Material & methods: Six children with an average age of 23 months and 1 case aged 12 years old, had a medial contracture of the shoulder secondary to a C5–C6 ( 3 cases) or C5–C7 (4 cases) obstetrical palsy. An arthroscopic evaluation of the deformities was performed in 3 cases. Next a surgical subscapularis release was applied in association with a latissimus dorsi transfer.

An arthroscopic evaluation of the joint associated with an arthroscopic capsular release (release of the coracohumeral ligament) was performed in 4 cases. In addition, the latissimus dorsi was transfered. Pre and Post operative passive external rotation were measured in degrees in R1 position.

Pre and post operative medial rotation were evaluated according to the Mallet classification. A comparative evaluation of the glenohumeral deformities were performed between pre-operative MRI and arthroscopic results.

Results: An arthroscopic evaluation of the glenohumeral joint was performed in 6 cases. In one case the arthroscopic evaluation could not be performed. In the 6 cases, arthroscopy confirmed the MRI lesion : 3 posterior subluxations, 1 posterior luxation and 2 normal joints. The subscapularis release allowed an increase in the passive lateral rotation of an average of 50°. However, a decrease of 1 point in the medial rotation was noted according to Mallet evaluation. The coracohumeral ligament arthroscopic release allowed an increase in the passive lateral rotation of an average of 60° without decreasing the passive medial rotation. Whatever the method used, a reduction of the subluxation of the glenohumeral joint was obtained.

Discussion & Conclusion: Medial contracture of the shoulder may begin in the first two years of life and an early reduction with muscular release and transfers was proposed. However, the precise nature of the progressive limitation of the external passive rotation remains unclear. Is the limitation due to a contracture of the medial rotators or a capsular retraction or a combination of both? Harryman demonstrated the role of the rotator interval capsule and coracohumeral ligament in limiting the external rotation. Our hypothesis was that capsular retraction occurred before the muscular contracture. As a result we decided to perform a capsular release in patients under 24 months. The results on the passive external rotation were similar with both methods. Although, the technique of an arthroscopic release was difficult and demanding, it appears that this technique is beneficial as it allows an evaluation of the joint deformity and treatment of the contracture in the same time.

Arthroscopic release is a safe but demanding technique which allows an increase in the external passive rotation in OBPP. It should be noted that this technique requires a significant practice.

Purpose of the study: To analyse the ability of Blount’s technique (closed reduction and immobilisation with a collar and cuff sling) for the treatment of completely displaced extension-type (Gartland III) supracondylar fracture of the humerus in children.

Introduction: Blount’s technique is usually considered to be unreliable for completely displaced extension-type supracondylar fracture of the humerus. According to the literature, it increases the risks of secondary displacement and neurovascular complications. Consequently, many authors prefer traction or internal fixation with K-wires. Nevertheless, some authors stated that Blount’s technique can be efficient in selected cases of type-III fractures. As we usually used Blount’s technique in our Institution even in cases of type-III fractures we decided to analyse our results.

Material and method: we evaluated retrospectively 46 consecutive cases of completely displaced supracondylar fractures of the humerus treated in our Institution. Mean age was 7 years (3–11). There were 31 left side and 15 right side, 35 males and 11 females. 7 patients who had associated fracture of the forearm or neurovascular damage were treated surgically and stabilised with pins. In 39 patients where the fracture was isolated without initial neurovascular complication, closed reduction under general anesthesia and stabilization with a collar according to Blount’s technique was first attempted. Results: Among the 39 patients where Blount’s technique was used, external reduction failed in 8 cases (in 5 cases, the reduction was not satisfactory, and in 3 cases, the reduction was unstable). These 8 patients were operated during the same anesthesia. Reduction and stabilisation was achieved by open reduction and pinning. Among the remaining 31 patients where closed reduction and external stabilisation could be achieved, we did not note any neurovascular complication or compartment syndrome. 8 days postoperatively, secondary displacement was noted in 2 patients. These 2 patients had operative treatment. The 29 remaining patients were reviewed with a mean follow-up of 29 months (2–6 years). Consolidation was obtained between 30 and 45 days in all cases. At the final follow-up, according to Flynn’s overall modified classification, the clinical result was considered to be excellent in 26 patients and good in 3 patients where a 10° limitation of flexion was noted. The carrying angle was identical to the controlateral side in all cases. Radiographic assessment using Baumann angle was normal in all 29 cases (65° to 75°).

Conclusion: Blount’s technique can be used in selected cases of completely displaced extension-type supracondylar fractures of the humerus in children. It appears to be safe and reliable if a perfect and stable initial reduction can be obtained.