Purpose of the study: A stiff shoulder in internal rotation is a classical complication of obstetrical injury to the brachial plexus. The condition generally associates glenohumeral dysplasia. In 2003, Pearl proposed arthroscopic release of the shoulder, with or without latissimus dorsi transfer as an alternative to an open procedure. We report a series of 13 patients who underwent this procedure.

Material and method: From 2004 to 2007, 13 children aged 1 to 11 years (range 3.5) underwent surgery. The procedure was an arthroscopic tenotomy of the intra-articular portion of the subscapularis associated with release of the anterior capsuloligament structures without tendon transfer. A thoracobrachial resin cast maintained the shoulder in maximal external rotation for six weeks. The functional outcome was assessed on the basis of the passive and active range of motion and the Mallet score. Pre and postoperative MRI was used to assess glenohumeral dysplasia and check its correction.

Results: Mean follow-up was 23 months (range 5–40). There were no complications. Mean immediate postoperative gain was 53 (range 30–70) for external rotation (RE1). On average, passive RE1 improved from −5.4 to +57.7. Eight patients (61%) recovered active external rotation (57.5 on average). Mean active abduction improved from 45.8 to 56.5. Active internal rotation declined in 38% of the shoulders. The Mallet score improved in 69% of the shoulders. The best results were observed for children aged less than 4 years. There was one failure, related to major dyplasia which could not be reduced with an open procedure. Correction of the glenohumeral dysplasia was noted on 7 of the 9 MRI performed and the retroversion angle of the glenoid improved from −28.2 to −25.6, on average.

Discussion: Open techniques are aggressive and only variably effective. A majority of our patients (8/13) achieved improved passive and active RE1 solely with the arthroscopic procedure. Correction of the glenohumeral dysplasia with growth appears to correspond to the clinical improvement but further follow-up is needed.

Conclusion: Our results are comparable with those reported by Pearl. This is a minimally invasive easy-to-perform technique. For children aged less than 4 years, systematic tendon transfer does not appear to be necessary.

Purpose of the study: Amputation of the thumb is a serious hand injury producing a major functional and aesthetic handicap. In 1980, Foucher proposed a twisted two toes transfer associating elements harvested from the first and second toes on the same pedicle for the reconstruction of an ‘articulated’ thumb with preserved potential for growth.

Material and method: Since 2002, two children aged 10 and 14 years underwent this procedure. The thumb amputation was trans MP for one and at the base of P1 for the second. The transfer associated a sheath of skin from the hallux to wrap around the skeleton of the second toe which was harvested as need to the IP or the MP. The aesthetic, functional (400 point scale), and radiological outcomes were assessed.

Results: Follow-up was 5 years and 2.5 years. The aesthetic result was comparable to wrap-around transfers. Regarding the functional outcome, the overall hand function was scored 86% and 72% of normal, mobility 77% and 72%, and force 75% and 79%. One patient had persistent deficient active flexion of the interphalangeal joint because of flexor adherences. Despite the reconstruction of the “two-joint” thumb, fine movements were difficult. Sensitivity was noted normal: Weber 5 and 8 mm. Healing of the donor site was rapid and the sequelae discrete. The first ray was preserved. Gait was not hindered. In one patient, radiographs showed skeleton growth.

Discussion: Transfer of the second toe provides a potential for growth, but the aspect is less than satisfactory and the functional results often disappointing. There are no indications except for very proximal amputations. Total transfer of the great toe would also provide potential for growth, but the voluminous aspect and the very important sequelae for the foot rule out this option.

Conclusion: For growing children, the twisted two toe transfer for amputations of the metacarpophalangeal region is the only available technique allowing nearly normal reconstruction of the thumb in terms of mobility, force, sensitivity, appearance, and growth. The foot reconstruction is simple, aesthetic and functional. The complexity of the procedure may nevertheless limit is use.

Purpose of the study: It is relatively rare to observe villonodular synovitis in children. The predominant localization is in the large joints. Histology is required for definitive diagnosis but specific sequences of magnetic resonance imaging (MRI) has greatly improved diagnostic performance.

Material ad methods: we report four cases of hemopigmented villonodular synovitis observed in four girls aged 11–16 years (mean age 12 years) at diagnosis. Localizations were the knee joint in two, the metacarpophalangeal joint of the third finger in one and an intracarpal joint with scaphoid defects in the fourth. Plain x-rays centered on the joint involved and MRI spin echo T1 and T2 with fat saturation were obtained for all four children. Echo gradient with long TE sequences were also performed for the last two children because of the anomalies observed in the first two.

Results: The MRI findings enabled the diagnosis of hemopigmented villonocular synovitis in all four patients and was confirmed histologically (two biopsy specimens followed by dissection and two first-intention dissection specimens).

Discussion: The large joint localizations are often reported but the two cases involving the wrist and fingers are less common. The condition is usually revealed by repeated joint effusion which if punctured generally reveals a hematic discharge. Pain is classical and a mass is often palpated. Standard x-rays show intraosseous defects and MRI, using the three sequences together, generally provides the diagnosis. On the spin echo T1 sequence the synovial mass gives an intermediate signal compared with the low intensity signal of the joint fluid since the cholesterol deposits enhance the signal. In spin echo T2 sequence with fat saturation, the lesion produces a heterogeneous signal which is still intermediary because of the hemosiderin and cholesterol deposits which decrease the inflammatory aspect of the synovitis. These signs are highly suggestive and should be followed by an echo gradient long TE sequence. This is not a routine sequence but provides objective evidence of hyposignals within the synovial mass. This type of signal is specific for the presence of iron and thus hemosiderin.

Conclusion: MRI is the exploration of choice for the diagnosis of hemopigmented villonodular synovitis. It enables postoperative monitoring in search of recurrence.

Purpose: The bifoliated vascularised fibula graft is an attractive alternative for reconstruction of large bone segments. The purpose of this work was to evaluate mid-term results and the usefulness of two surgical techniques: skin island flap monitoring and the arterio-venous loop.

Material and methods: This retrospective analysis included fourteen patients (eleven men and three women) treated between 1992 and 2002. Mean age was 30 years (10–54). Indications were complications of open fractures in nine patients, major bone loss in two, septic nonunion in four, and aseptic nonunion in three. Reconstruction was performed after bone tumour resection in five patients involving immediate reconstruction after failure of an infected massive allograft in four of them. Localisations were: tibia (n=6), femur (n=5), humerus (n=2), and pelvis (n=1). Average bone loss was 10 cm (7–15 cm). Minimal pinning, cerclage or screwing was used to stabilise the flap completed by internal fixation in four patients and external fixation in ten. A monitoring skin island was used for twelve patients (the island was technically impossible in two patients). Vascular anastomoses were performed in seven patients using an arteriovenous loop, performed as a preliminary measure in six.

Results: Mean follow-up was 35 months. One patient died early from tumour progression. Among the seven patients who had an arteriovenous loop, one required revision for a vascular complication. For the seven “classical” bypasses, there were three intraoperative or early complications requiring revision of the anastomoses. Nonunion developed despite early revision in the four patients whose monitoring skin island suffered. Consolidation was achieved without revision in all patients who skin island did not suffer; time to bone healing was eleven months for seven of them.

Conclusion: Bone healing was related to the quality of graft vacularisation. Clinical observation of the monitoring island was the best way to identify vascular complications early and initiate treatment. Use of a preliminary arteriovenous loop decreased the risk of vascular insufficiency inherent with long bypasses and shortened operative time.

Purpose: Transscaphoretrolunate dislocation is the most frequent perilunate dislocation of the carpus (65% according to Herzberg). Treatment remains controversial. The aim of this work was to analyse functional outcome in a homogeneous series of 15 patients treated by open reduction and fixation.

Material and methods: This retrospective analysis of 15 patients, mean age 34 years was conducted at four years follow-up. Clinical outcome was based on the Cooney clinical scoring chart. Static and dynamic x-rays of the wrist were studied. The dislocations were: type I=9, type IIa=5, type II=1 according to the Alnot classification. The scaphoid fractures were: types III and IV=13, type II=2. A dorsal approach was used for six cases, an anterolateral approach for four and a double approach for five. The carpal tunnel was opened in seven cases. The scaphid fracture was fixed by pins in eleven cases, by screws in four, and associated with a corticocancellous graft in five. The carpus was fixed in seven cases with scapholunate pins, with lunotriquetral pins in seven, and radiolunate pins in three.

Results: Mean score was 70±20% with mean flexion 50±17° and mean extension 54±20°. Grip force was 32/45±11 (Jamar). The thumb-index force was 14±5.1. Pain was negligible in 33% of the patients and was disabling in 17%. Climatic pain was reported by 50% of patients; 75% were able to resume their occupational activities. Radiographically we found osetonecrosis of the lunate (n=1), osteonecrosis of the proximal pole of the scaphoid (n=2), non-union of the scaphoid (n=3), radiocarpal osteoarthritis (n=4), SLAC (n=1) and SNAC (n=2).

Discussion: Our outcomes were slightly less favourable than those reported in the literature concerning joint motion. Conversely, for pain, duration of sick leave, and percentage of occupational reclassing, our results were the same as reported in the literature. The series shows that radiographic outcome was favourable with 13% radiocarpal osteoarthritis (38% for Herzberg in 2002 at 96 months. The stability of the scaphoid osteosynthesis remains the key to success (two nonunions for four single pin fixatons). A new analysis at longer follow-up would be interesting to determine the arthrogenic results.

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: The antecubital flap described in 1983 by Lamberti and Cormak fed by the first proximal collateral of the radial artery is not widely used. We propose a clinical series of seven patients where this flap was used to demonstrate its interest for elbow substance loss.

Material and method: Our series included seven patients operated on between 1998 and 2000. There were six men and one woman, mean age 33.5 years (2′–53). Tissue loss ranged form 20 to 90cm2. Tissue harvesting ranged from 20 to 108 cm2. For four cases the tissue loss was limited to the olecranon and the epitrochlear area in a traffic accident victim. In all cases bone exposure required coverage. The lateral cutaneous nerve of the forearm was harvested in all cases with the flap to provide adequate sensitivity. Mean operative time was 1 h 15 min.

Results: All flaps survived. Elbow amplitudes remained normal. Sensorial disorders resulting form the lateral cutaneous nerve removal from the forearm were considered insignificant by all patients. The patients found the scar to be satisfactory.

Discussion: There have been few reports on the usefulness of this flap. Our clinical experience suggests the antecubital flap is a reliable flap which is easy and rapid to perform.

Anteriorly displaced fractures of the wrist can be treated by the Kapandji technique of percutaneous intrafocal pinning with pins inserted through an anterior approach to give good reduction and stabilisation of the fracture. We have modified this technique by placing the pins through a posterior approach which decreases the risks of neurovascular damage.

We have used this method to treat six children with distal radial fractures showing anterior displacement or instability. Good anterior stabilisation was achieved. The pins were removed at an average of eight weeks and the patients were then able to return to full activity.

This simple technique can be used for unstable fractures after the failure of conservative treatment or in bilateral fractures in adolescents.