In this study we evaluated the results of midtarsal release and open reduction for the treatment of children with convex congenital foot (CCF) (vertical talus) and compared them with the published results of peritalar release. Between 1977 and 2009, a total of 22 children (31 feet) underwent this procedure. In 15 children (48%) the CCF was isolated and in the remainder it was not (seven with arthrogryposis, two with spinal dysraphism, one with a polymalformative syndrome and six with an undefined neurological disorder).

Pre-operatively, the mean tibiotalar angle was 150.2° (106° to 175°) and the mean calcaneal pitch angle was -19.3° (-72° to 4°). The procedure included talonavicular and calcaneocuboid joint capsulotomies, lengthening of tendons of tibialis anterior and the extensors of the toes, allowing reduction of the midtarsal joints. Lengthening of the Achilles tendon was necessary in 23 feet (74%).

The mean follow-up was 11 years (2 to 21). The results, as assessed by the Adelaar score, were good in 24 feet (77.4%), fair in six (19.3%) and poor in one foot (3.3%), with no difference between those with isolated CCF and those without. The mean American Orthopaedic Foot and Ankle Society midfoot score was 89.9 (54 to 100) and 77.8 (36 to 93) for those with isolated CCF and those without, respectively. At the final follow-up, the mean tibiotalar (120°; 90 to 152) and calcaneal pitch angles (4°; -13 to 22) had improved significantly (p < 0.0001). Dislocation of the talonavicular and calcaneocuboid joints was completely reduced in 22 (70.9%) and 29 (93.6%) of feet, respectively. Three children (five feet) underwent further surgery at a mean of 8.5 years post-operatively, three with pes planovalgus and two in whom the deformity had been undercorrected. No child developed avascular necrosis of the talus.

Midtarsal joint release and open reduction is a satisfactory procedure, which may provide better results than peritalar release. Complications include the development of pes planovalgus and persistent dorsal subluxation of the talonavicular joint.

Cite this article: Bone Joint J 2014;96-B:837–44.

For many surgeons amputation is the usual treatment in sarcoma of the foot. The aim of our study was to report the functional and oncologic results of treatment in 54 sarcomas of the foot to assess if conservative treatment was acceptable

We retrospectively reviewed the records of 54 patients with sarcomas of the foot, aged 6 to 50 (mean 17), 30 females and 26 males. At time of referral, 18 had a local recurrence of a previous inadequate treatment. There were 27 soft tissue sarcomas (STS: 10 synovial sarcomas, 6 rhadomyosarcomas, 1 liposarcomas and 10 others) and 27 bone tumours (16 Ewing's, 8 chondrosarcomas, 3 osteosarcomas). Toes tumours were excluded, 18 tumours involved the metatarsal, 12 the plantar soft tissues, 11 the calcaneum, 3 the talus, 2 the midtarsal bones.

Surgery consisted in 19 resection without reconstruction, 21 resections with bone reconstruction, 9 partial amputations of the foot, and 6 trans tibial amputations.

In 34 cases surgical margins were adequate (R0), in 13 patients resection was inadequate (9 R1 and 4 R2). In 7 cases the margins were not assessed.

After a 5.5 years average follow-up (3m to 17y), 31 patients had no evidence of disease, 8 were in second remission, 4 had an evolutive disease and 11 were deceased. The mean MSTS score was 26/30 (31 cases).

In conclusion, a conservative treatment is feasible in metatarsal bones with skin coverage by flap if necessary. In STS adequate margins are difficult to achieve with a high rate of local recurrence. In calcaneus and talus, a conservative treatment is possible in tumours limited to bone after good response to chemotherapy. In other cases conservative treatment is debatable because amputation gives excellent functional results.

Purpose of the study: Data are scarce on the long-term outcome after anterior spinal fusion for idiopathic scoliosis in adolescents. The purpose of this study was to assess the clinical and radiological results obtained in a monocentric series using a single-phase fusion with pre-formed plates for the treatment of lumbar, thoracolum-bar and thoracic idiopathic scoliosis in adolescents.

Material and method: This procedure was performed in 111 patients from 1975 to 1993. Complete clinical and radiological evaluations were available for 35 patients, 7 male and 28 female. The SRS-30 questionnaire (translated into French by the authors) and the Oswestry score were used to assess functional outcome. Radiographic data were collected by an independent observer who read the pre-, post- and last follow-up images. Full spine images were available to assess correction of the curvature, frontal and sagittal balance, pelvic parameters, and degenerative changes in the subjacent discs. Functional outcome was assessed in relation to the radiographic findings.

Results: Mean follow-up was 22 years (range 16–31). Mean age at surgery was 14.5 years. At last follow-up, none of the patients were unemployed because of a spinal problem and 21 women had had one or more successful pregnancies. The mean SRS-30 score was 3.8/5 and correlated with the Oswestry score (13.8%). One patient underwent revision for disc herniation and one for posterolateral lumbosacral fusion because of persistent frontal imbalance. There as a fracture of the proximal screw in six patients with no sign of nonunion. At last follow-up, the mean Cobb angle was 14 (0–42). Frontal imbalance was noted in 18 patients, mean 12 mm. In the sagittal plane, three patients presented anterior imbalance. The pelvic parameters were within the range of the general population. Signs of L5-S1 disc degeneration were noted in ten patients, with no correlation with functional outcome.

Conclusion: Anterior fusion gives good long-term functional results in the treatment of idiopathic scoliosis in adolescents. Patients can pursue a normal occupational and familial life. This technique has provided satisfactory correction in the frontal and sagittal planes.

Purpose of the study: Lengthening can be proposed for children with congenital or acquired short fingers in order to overcome the length defect and improve function, the aesthetic aspect, or enable installation of a hand prosthesis. Three techniques have been proposed. The purpose of this study was to compare the three techniques in terms of lengthening, achieved, cure index, and complication rate.

Material and method: The was a series of 13 lengthening procedures for metacarpals in children with congenital or post-trauma sequelae.

Results: The callotasis method was used for seven children. Slow distraction using a mini-external fixator was applied for progressive lengthening without bone graft. Mean lengthening was 13 mm (range 8–21) for mean a mean cure index of 81 d/cm (range 41.7 to 140.9). There was one major complication: fracture with angulation. The two-phase progressive distraction method with graft was used in four children. The distraction using a mini-external fixator was rapid, followed by second phase bone graft. Mean lengthening was 22 mm (range 13–32) with a cur index of 40.8 d/cm (range 32.8 to 46). There was one fracture of a grafted zone. Single-phase extemporaneous lengthening with immediate graft was used for two children. The intraoperative distraction of the osteotomy was followed immediately by insertion of the graft. Mean lengthening was 9 mm for a cure index of 50 d/cm. One patient required tenolysis of the extensor at six months because of adherences at the graft site.

Discussion: Our results suggest that the two- phase distraction-graft method enables greater lengthening than the callatasis technique for shorter treatment periods but a the cost of a second operation and donor site morbidity. The extemporaneous lengthening method is less ambitious, achieving lengthening to the order of 10 mm, but with a less aggressive procedure.

Purpose of the study: We noted that four postoperative compartment syndromes observed in our department occurred in short stature patients with micromely secondary to chondrodysplasia. This complication occurred in young subjects with significant muscular development (two with intensive sports practice) whose muscle hypertrophy appeared exaggerated by the short length of the limbs.

Material and methods: The first case concerned a young man with pycnodysostosis who developed a tibial compartment syndrome after prolonged ventral decubitus subsequent to spinal surgery. No surgical procedure had been performed on the lower limb. The complication was probably triggered by simple compression of the proximal portion of the limb leading to elevated venous pressure and rapid self-aggravating muscular atrophy in a small aponeurotic compartment. The second case was a female patient with metaphyseal dysplasia who during adolescence had undergone corrective bilateral tibial osteotomy to align the lower limbs. Preventive aponeurotomy had been performed which left on one side a disgraceful muscle herniation. Aponeurotic plasty had been performed in adulthood to reconstitute the tibial compartment. A compartment syndrome developed in the immediate postoperative period. The third case was a young adult with hypochondroplasia who developed bilateral crural compartment syndrome 24 hours after femoral osteotomy with implantation of an external fixator for lower limb lengthening.

Results: Sequelae were observed in only one of these four cases of compartment syndrome (patient n° 1). Extensive necrosis of the tibialis anterior was observed due to late diagnosis, leading to legal implications and a court suit. Emergency treatment was given in the three other cases and no sequelae were observed.

Discussion: These patients with chondrodysplasia and micromely appeared to be predisposed to postoperative compartment syndrome because of the relative muscle hypertrophy and the narrow muscle compartments. The risk of this complication in small stature patients warrants the use of preventive aponeurotomy during orthopedic procedures involving the limbs and implies rigorous postoperative surveillance for early detection. Systematic aponeurotomies should be extended over the entire length of the muscle compartment involved in order to achieve effective decompression and avoid disgraceful localized muscle herniation.

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.

Purpose of the study: Determine the prevalence and course of spinal deformations in Willi-Prader syndrome and assess the effect of treatment with growth hormone. Analyze outcome after conservative and surgical treatments.

Material and methods: We reviewed the files of 51 patients with Willi-Prader syndrome proven genetically. Spinal deformations were classed according to the SRS system. Body mass index (BMI) was determined and correlated with age and administration of growth hormone. Statistical analysis used the coefficient of correlation and the chi-square test to search for correlations between qualitative variables.

Results: There were 37 girls and 24 boys, mean age at last follow-up 10.7±6.7 years. The prevalence of scoliosis was 52% and varied according to genotype.

The prevalence of scoliosis deformations was higher in patients aged over ten years (p< 0.01). The prevalence of scoliosis was greater in female patients. Patients with BMI< 25 had a significantly lower risk of scoliosis. Treatment with growth hormone was associated with a significant decrease in risk of scoliosis. Among scoliosis patients, ten had a main curvature < 15° and were monitored. Eleven had a curvature > 15° (31±11°) and were treated with a corset. Five had a curvature > 50° and trunk imbalance and were treated surgically. Four of these patients developed serious complications.

Discussion: Scoliosis deformation is frequent in Willi-Prader syndrome. Weight control is very important and BMI should be maintained below 25 to limit the risk of scoliosis. Treatment with growth hormone helps limit BMI and thus the risk of scoliosis. For major deformations, surgical treatment is indicated but at the risk of serious postoperative complications.

Purpose of the study: Even more so than adults, children are exposed to serious foot trauma caused by lawn mowers, bicycle spokes, or car wheels. These different mechanisms produce specific lesions to the rear foot or the toes and the dorsal aspect of the foot. Each type of lesion raises specific problems concerning emergency cover. Sequelae evolve with growth. We present a series of thirteen children given emergency treatment then long-term care over periods of six months to twenty years.

Material and results: The heel was amputated in four children (lawn mower or bicycle spoke accidents). Cover was obtained with a sural (three first-intention) neurovascular island flap with a distal pedicle. The long-term assessment evaluated function as well as residual growth of the calcaneum. Four lawn mower accidents produced lesions involving the toes and the mediotarsal area which did not require emergency flap cover. Dorsal retractions occurred in all four cases and progressed secondarily, later requiring a good quality skin flap and dorsal release. In five children lesions of the toes, forefoot, or the entire foot occurred in five children whose foot was crushed under car (or truck) wheels or was injured during fall from a wall. In these children, the urgent or secondary skin problems predominated in the dorsal area and required a variety of flaps.

Discussion: «Dorsal trauma» appears to have a predominant effect in children because the toe alignment during growth is directly dependent on the flexibility of the dorsal tissues. Several flaps can be used for this indication but are often difficult to achieve for the more distal areas (commissures and toes). Heel reconstruction is also a difficult challenge with the problem of sensitivity and tissue quality. It does not resolve the problem raised by amputation of the posterior calcaneal growth nucleus.

Purpose: We reviewed our pre-puberty patients whose scoliosis or kyphoscoliosis involved a hemivertebra. The purpose of our work was to evaluate the surgical technique used and evaluate spinal static as well as functional outcome at skeletal maturity.

Material and methods: This retrospective analysis included 21 patients who underwent surgery before the age of 10 years and were followed to skeletal maturity. We excluded children with a multiple malformation syndrome or multiple vertebral malformations. The type and localisation of the hemivertebra was noted. Deformation, transversal balance, and radiographic measures were recorded preoperatively. Elements contributing to the indication for surgery, the type of procedure, and complications were also recorded. Events recorded during growth were the clinical course, complementary treatments, and possible surgical revision. Functional and aesthetic outcome was assessed at last follow-up. Spinal deviation was measured and compared with the preoperative angles.

Results: Twenty-one children (13 girls, 8 boys), mean age three years ten months (range 10 months – 10 years) met the inclusion criteria. These children had a hemivertebra of the thoracic spine (n=9), the thoracolumbar junction (n=4), the lumbar spine (n=4), or the lumbosacral region (n=4). Surgery was indicated to arrest clinical and radiographic degradation. Several surgical procedures were used: fusion without resection for thoracic vertebrae and resection associated with arthrodesis or epiphysiodesis for other localisations. There were five complications: neurological (n=2), infectious (n=2) and disassembly (n=1). The clinical and radiographic course led to revision in ten children, including two who required a new operation. At mean follow-up of 14 years (9–23 years), the functional outcome was good in 19 patients, poor in one patient with a lumbosacral hemivertebra and in another with a thoracic hemivertebra. The aesthetic result was good in 16 patients. Five of the nine patients with a thoracic hemivertebra remained unsatisfied with the outcome. Mean curvature correction ranged from 26% at the thoracic level to 50% at the thoracolumbar and lumbosacral levels and 75% at the lumbar level.

Discussion: The long follow-up of this series is exceptional. Treatment of evolving spinal malformations is a difficult challenge. Early surgery does not guarantee the final outcome and 50% of patients have to be reoperated at the end of growth. The good long-term functional and aesthetic outcome is however encouraging, particularly when hemivertebrectomy can be performed.

Purpose: From 1985 to 2001, 31 total knee arthroplasties were performed for 17 adolescents or young adults with idiopathic juvenile osteoarthritis. The purpose of this work was to evaluate functional and radiological outcome.

Material and methods: Overall functional outcome was assessed with the Steinbrocker classification. Knee function was evaluated with the IKS score. Several types of prostheses were implanted: constrained GSB (n=14), cemented semi-constrained tri-CCC tri-compartment with a rotatory platform (n=10), non-cemented semi-constrained ROCC (n=1), LCS (n=2) including non-cemented, and FINN (n=2) (two custom-made rotation hinge prostheses implanted in the same patient). Fourteen prostheses involved bilateral implants, including three dual implantation procedures.

Results: Mean age at implantation was 20 years five months (14–29). There were fourteen girls and three boys. Eight had systemic idiopathic juvenile osteoarthritis and nine a polyarticular form. The Steinbrocker staging was: II (n=5,) III (n=6), IV or bedridden (n=4). Ten patients had two hip prostheses before bilateral knee arthroplasty. Mean follow-up was 4.5 years (1–12). Among the 31 operated knees, 16 were pain free, 14 minimally painful, and one painful due to loosening. The joint score was very good (n=18), good (n=4), and poor (n=5). Radiographically, normal alignment was found for 29 knees. Lucent lines were observed for 10 of the 14 GSB constrained prostheses. We did not observe any evidence of lucent lines for the non-cemented tri-compartment prostheses. Complications were: limited skin necrosis (n=1), bilateral supracondylar fracture one year after implantation (n=1).

Discussion: Outcome has been encouraging for total knee prostheses in patients with idiopathic juvenile osteoarthritis. These arthroplasties allow spectacular functional improvement. The few series reported have also reported very good results. Cemented tri-compartment semi-constrained implants appear to provide better stability at five years. Biologically sealed tri-compartment prostheses would be a very satisfactory solution due to the preservation of bone stock.

Purpose: We expose technical problems encountered for prosthesis replacement in osteoarthrosis juvenilis (OJ). The characteristic feature of this disease is early joint destruction during growth.

Material and methods: Total knee arthoplasty (TKA) was performed in 17 severely disabled patients (31 knees): Steinbrocker stage II=30%, stage III=30%, stage IV=40%. Mean age at operation was twenty years (14–29). Technical difficulties were related to the following combinations: 1) multidirectional malformations, generally in valgus (mean 16°, range 5–30°) in 30% of the knees associated with external rotation (mean 20°, range 5–50) and sagittal deformation with permanent flexion (mean 31°, range 5–60°) with external or posterior tibia dislocation; 2) limited joint motion: 71° (0–115°); 3) extraarticular deformations with permanent flexion or vicious hip rotation, tibial or femoral callus; 4) major condyle dysplasia due to growth deficiency (3/31 or necrosis (3/31); 5) low patella (100%) and subluxation; 6) weak bone and fragile skin related to corticosteroid therapy; 7) persistent growth cartilage in four patients. We tried to implant the most adapted prosthesis in each individual situation, favouring the least constrained implant possible.

Results: We used fifteen mobile plateau prostheses including five pure gliding TKA and ten posterostabilised TKA with a mobile plateau and 16 hinge prostheses with two rotators. Thirty of the 31 TKA were custom-made.

Discussion: Our different approaches enabled us to propose the following: correction of extra-articular deformations by TKA, after tenotomy and traction, or after concomitant osteotomy; primary approach after checking the vasculonervous bundle (popliteal sciatic); sub-periosteal dissection preserving the lateral ligaments searching to achieve ligament balance when possible in order to implant the least constrained implant possible; non-cemented implants, especially for “soft” or “fatty” bone; no patellar resurfacing when there is a risk of an overly thick low and subluxed patella.

Introduction: The management of a hip destroyed by infection during growth is difficult and controversial. Two clinical cases illustrate differing management options and question what might be the best solution for this problem.

Case 1: A 12-year-old girl presented with a Staphylococcus aureus septic arthritis of the left hip. She underwent an arthrodesis of the hip one-year later because of a poor position of the hip. She had 20mm of shortening of the left lower limb. After 6 years of “normal” life she received a total hip replacement when aged 19 years. Since then she has no pain and has 12 mm of shortening of her left lower limb and a mobile left hip (100/0, 40/30, 30/30) and works as a cashier.

Case 2 A 2-year-old boy presented with a Salmonella septicaemia and septic arthritis of the right hip. The hip deteriorated but the parents refused a hip arthrodesis. He underwent a Colonna procedure in 1994. Five years later he had developed 50mm of shortening in the right lower limb and he had an epiphysiodesis of the left knee. He is now 17 years old, has a painless hip, satisfactory range of movement (90/0, 0/15, 5/5), a slight limp, equal leg length and enjoys normal teenager activities. Radiographs suggest that he would benefit from a hip replacement.

Purpose: Tillaux fractures correspond to type III joint fractures involving the anterolateral tubercle of the inferior tibia in the Salter and Harris classification. These fractures generally occur by external rotation in children about 13 years old at the time the medial part of inferior growth cartilage of the tibial epiphysis has fused. The purpose of the present study was to analyse long-term outcome in a retrospective series of twenty children.

Material and methods: All twenty patients underwent physical examination and a standard radiographic work-up at last follow-up. Results were classed into three categories: good (free of pain, stiffness, gait impairment, joint degeneration), faire (moderate pain and/or stiffness and/or gait impairment without joint degeneration), poor (severe pain and/or severe stiffness and/or limping and/or joint degeneration).

Results: This series included eight boys and twelve girls, mean age 12.8 years (range 3.4 – 14.9). Mean follow-up was three years eleven months (range 12 months – 8 years 9 months). Eleven patients underwent surgical treatment and nine orthopaedic treatment. The lateral segment of the growth cartilage was open in all cases but the medial segment was open in two and completely closed in six. A computed tomography scan was required in one patient to assess displacement. Outcome was considered good in eighteen patients and fair in two. These two patients had persistent pain without functional impairment at about one year follow-up.

Discussion: Overall, the long-term outcome is good for Tillaux fractures if they are correctly identified and evaluated, with computed tomography if necessary, to enable appropriate surgical or orthopaedic treatment. Inappropriate management of this joint fracture can lead to joint incongruency and secondary degeneration. Most of these fractures occur in adolescents and secondary growth impairment is negligible. This type of fracture may also occur in adults. Prognosis is excellent with adapted treatment.