Purpose of the study: There remains some debate on the proper treatment of congenital dislocation of the patella in children and adolescents. Ligament-periosteum transfer (green-stick method) is a technique adapted for pediatric patients which realigns the distal extensor system.

Material and methods: Between 1979 and 2000, 36 children (51 knees) were treated with this method described by Grammont. Section of the lateral wing and medial capsulomyoplasty were associated in all procedures. Other complementary procedures used as needed included lengthening of the quadriceps, trochleoplasty, and quadriceps release. Mean age at surgery was 11 years (range 5–15 years). All patients were reviewed at bone maturity with a mean follow-up of 7.5 years for functional (IKC criteria) and radiographic assessment. A computed tomography and/or magnetic resonance imaging was obtained preoperatively and at last follow-up to assess TAGT, patellar height, trochlear angle, femoral anteversion, external tibial torsion, and knee rotation. Tibial slope was specifically studied to assess the possible epiphysiodesis effect.

Results: Two groups of patients were distinguished: congenital dislocation of the patella (persistent or usual) and objective patellar instability. Functional outcome was good in 74% and 87% of the knees. There were eight cases of recurrent dislocation: five knees were operated on with good outcome. The trochlear angle was improved in both groups, more significantly in the congenital dislocation group. There was one case of an inverted tibial slope (−2°) and two cases of cancelled slope.

Discussion: Our functional results are in agreement with earlier reports (Grammont, Bensahel, Langeskiold) but comparison is hindered by the heterogeneous nature of the different cohorts. Radiographically, we observed that trochlear remodeling, a sign of good stability, is better if the operation is performed early (before the age of ten years). On the contrary, in adolescents with major patellar instability, complementary trocheloplasty should be performed in addition to the recentering procedure. We observed that a small tibial slope became smaller in eleven knees in comparison with the nonoperated knee and in comparison with the preoperative slope for the bilateral cases. There appears to be a discrete epiphysiodesis effect but with no functional consequence.

Conclusion: We propose a classification of congenital dislocation of the patella in children. The ligament-periosteum transfer technique, associated with other procedures as needed, enables stabilizing the extensor system and a normal trochlear angle if surgery is performed at a young age. Remodeling of the tibial tubercle may result from transient disruption of the vascular supply.

Purpose: The risk of injuring the radial nerves during spine instrumentation to correct spinal deformity is well known and accounts for about 50% of the neurological complications associated with this type of surgery. We describe a technique for monitoring the nerve roots during spinal surgery. Radicular monitoring was described by Hormes in 1993.

Material and methods: We report a retrospective analysis of 73 procedures for spinal deformity during which the nerve roots were monitored. The series included 27 men and 46 women, mean age 23.9 years (range 4.5–74.9). Forty patients were less than 18 years old. Procedures included posterior arthrodesis (n=65) and anterior arthrodesis (n=8). Indications were: idiopathic scoliosis (n=32), neurological scoliosis (n=21), congenital scoliosis (n=4), spondylolisthesis (n=2) and kyphosis (n=3). The study group included 68 patients (168 roots) with recordings obtained under the required conditions. The routine procedure involved permanent electrophysiological monitoring of muscle activity with a multi-channel electromyograph. We used microwires implanted within the muscle itself for electrodes. Target muscles depended on the position of the planned implants and the topography of the roots likely to be endangered during the surgical procedure or instrumentation. Explored roots were: T12 (n=9), L1 (n=24, L2 (n=40), L3 (n=24), L4 (n=23), L5 (n=11), S1 (n=22). Monitoring prohibited use of curare during anaesthesia.

Results: Prior to radicular monitoring, we had had two root injuries (T12 and L3) which resolved spontaneous (n=139). During the study, changes in the radicular signal were observed in seven patients. All signal anomalies triggered a modification of the surgical procedure and no postoperative deficit was observed. Incidents observed concerned congenital scoliosis (n=2), neurological scoliosis (n=2), and idiopathic scoliosis (n=3). Roots involved were L1 (n=1), L2 (n=2), L3 (n=2), L4 (n= 4), i.e. 11/163.

Discussion: Continuous intraoperative monitoring of the spinal roots exposed to surgery for spinal deformity enabled us to identify eleven cases of root suffering among 163 recordings. This permanent monitoring system enabled us to immediately modify the surgical procedure and to control and conflict between the instrumentation and the roots or possible stretching during the correction. This technique requires permanent monitoring during the spinal procedure to avoid false negatives. Curare cannot be used.

Conclusion: Intraoperative radicular monitoring is an effective way to avoid radicular complications of this type of surgery. The technique is sensitive and allows immediate adaptation of the surgical procedure. It requires close collaboration between the neurophysiologist, the orthopaedic surgeon and the anaesthesiologist.

Introduction: Osteoid osteoma is a benign tumour that usually requires surgical excision as it commonly presents with severe and debilitating pain. Treatment by percutaneous drill resection with CTscan control was developed by Doyle, Voto & Kohler 15 years ago as an alternative to the classical “en bloc resection”. A series of 62 cases using this method is reported.

Method: The procedure is performed by an orthopaedic surgeon in the CT Scan room with the radiologist participation. The lesion (nidus) is localized on an appropriate CT slice. A special set of instruments (drill, trephine, reamer) are introduced in succession along a guide wire through a short skin incision. A small cylinder of bone is removed for histopathology analysis.

Between June 1987 and July 2003, 62 cases were so far treated. There were 13 adults (19 – 35 years) and 49 children and adolescents (2.5 years – 18 years). All patients had a clinical and radiological evidence for osteoid osteoma (hyperfixation on scintigraphy, visible nidus on CT scan). The nidus was mostly localized in the lower limb (53 cases) especially femoral neck (23), femoral shaft (13), tibial shaft (14).

Results: No severe complications were observed (delayed union after skin necrosis of the tibia in 3 cases, transitory palsy of extensor hallucis longus in one case. Clinical healing after a 1 year follow up was observed in all but 2 cases. In these 2 cases the lack of healing was considered as a failure of treatment and not true “recurrence”; a second attempt was successful. The nidus was confirmed in the specimen in half cases.

Discussion: This method has now clearly demonstrated its effectiveness and security. Benefits for patients are evident: thanks to minimal bone resection, quick recovery and immediate weight bearing are possible. This technique is now indicated in most cases, versus “en bloc resection” which should be considered only for some vertebral or superficial localizations of the nidus. Concurrently, other techniques have been recently developed : destruction by thermo coagulation or photocoagulation, which are similar to resection ; all are non invasive interventional procedure.

Purpose: A prospective study was conducted in 160 children presenting varus trauma of the ankle. The purpose of the study was to validate the Ottawa ankle rules in children. Application of the Ottawa rules can reduce the number of x-rays by 25% but little work has been reported concerning their validation (Chande 1995).

Material and methods: One hundred sixty children, 71 boys and 89 girls, mean age eleven years three months (range 3 – 15 years) were included in this study conducted between February 2001 and December 2001. Clinical presentations with an obvious diagnosis of ankle fracture were excluded (six patients). Epidemiological and clinical data and the initial Ottawa criteria were recorded on a data sheet with a specific number of assigned items. A standard radiographic work-up with an anteroposterior, lateral and oblique view of the ankle was obtained in all cases. All patients were seen at a second consultation on day 8 by another physician to confirm diagnosis. The x-rays were read three times: by the emergency care physician, and by a second physician and a paediatric orthopaedic surgeon at the 8-day consultation.

Results: Diagnosis which were confirmed were: benign sprains (BS) (n=71), moderately severe sprains (MS) (n=47), severe sprains (SS) (n=2), type I epiphyseal detachment (ED) (n=21), fractures (n=13) (8 fifth metatarsal, 1 triple fracture line, 1 medial malleolus, 2 lateral malleolus, 1 tarsal scaphoid).

For the Ottawa criteria, ankles positive for pain and at least one other criterion were: 64/77 BS, 43/47 MS, 2/2 SS, 21/21 DE and 13/13 fractures. All fractures were diagnosed at the first exam or at the 8-day exam.

Discussion: Based on our findings, the clinical Ottawa rules cannot be considered to be validated for children. Using these rules, x-rays would have been performed in 143 patients to identify 13 fractures that were not clinically obvious. Because the Ottawa rules are insufficiently specific for children, we recommend, like Brooks (1981) to use more rigorous clinical criteria for the diagnosis of ankle trauma in children.

The diagnostic criteria used in this study enabled correct first intention diagnosis in 129 patients with trauma. We propose ordering x-rays only for children with signs of moderate or severe sprain or pain in zone C (base of the fifth metatarsal: 8/8) or E (medial border of the foot: tarsal scaphoid fracture). For other cases (98/160) physical examination is sufficient.

Conclusion: We do not consider the Ottawa clinical rules to be valid for varus ankle trauma in children. We propose clinical criteria which can limit the number of x-ray work-ups by 60% in children with this type of trauma.