The aim of this study is to present and discuss some preliminary applications of tricalcium phosphate “Norian” in children and adolescents with different skeletal disorders. From 1997 to 2002 Norian was used as a biological bone substitute in 10 patients (six girls and four boys; mean age 11 years). The indications were four calcaneal cysts, one phalangeal enchondroma of the hand, one chondromyxoid fibroma of the tibia, one eosino-philic granuloma of the femur and one aneurysmal cyst of the tibia. Norian was also used as a bone graft in two Dega’s pelvic osteotomies. Follow-up was performed radiologically and clinically.

There was one deep infection in a calcaneal cyst which completely healed after curettage and antibiotic therapy and one soft tissue transitory painful reaction to Norian. All cases healed without complication and there was progressive osteointegration at radiological follow-up.

This preliminary study, even with different pathologies and a short follow-up, shows good biocompatibility of the material in the short- and mid-term, with satisfactory clinical results. Mechanical stability under compressive and shearing loads was detected when load bearing was allowed after 30 days in all cases.

Norian tricalcic phosphate is a good and strong bone substitute when a large autologus graft is needed as seen with distal fractures of the radius, tibial plateau and Dega’s pelvic osteotomy.

Adolescent hallux valgus is a progressive deformity of childhood. Patients with this disorder complain of pain, deformity, redness at the site of deformity, shoewear limitation and altered cosmesis. Surgery to correct the bunion is considered as pain gets worst, deformity increases or significant shoe wear limitation is present. However, there is still not an uniformly satisfying surgical treatment for the adolescent hallux valgus. This kind of surgery has been often associated with a high rate of recurrence and poor results. The adolescent condition often includes significant metatarsus primus varus as a primary element. This is the reason why isolated soft tissue procedures frequently fail. Surgical treatment often combines first metatarsal osteotomy with a soft tissue realignement of the first metatarsal phalangeal joint. Simmonds and Menelaus in 1960 reported their results with an osteotomy of the base of the first metatarsal in addition to McBride’s soft tissue recostruction. The procedure addresses the three main components of the adolescent hallux valgus deformity: the medial eminence, the hallux valgus and the metatarsus primus varus. Although Simmonds and Menelaus did not use any internal fixation to fix the osteotomy site, they performed a complete transverse osteotomy at the base of the first metatarsus. Besides they used an immobilization for six weeks in the post operative period. We describe a modified procedure where the osteotomy is performed incompletely at the base of the first metatarsal bone and we shortened the post operative immobilization period with a cast for three weeks. Simmonds’ procedure does not interfere with the sesamoid bones while in our method a repositioning of the sesamoids below the metatarsal head has been performed.

Materials and methods: From 1997 to 2000, 22 feet in 12 female and 1 male patients were treated surgically with the modified Simmonds-Menelaus bunion procedure. A primary operation was performed on all feet treated. The average age at surgery was 12.4 years (range 10.5 – 14.6 years). Preoperative, postoperative and final follow up evaluation included history, physical examination, record of range of motion of the first metatarsophalangeal joint, anteroposterior and lateral radiograph of the feet in the weight bearing position.

Results: Lenght of follow up averaged 3.9 years. The average pre operative Hallux Valgus Angle (HVA) was 31.2°. The average pre operative Inter Metatarsal Angle ( IMA) was 13.5°. The average HVA was reduced to 17.8°; the IMA was reduced to 11.3°. Of the 22 feet with preoperative subluxation of the sesamoids, all feet were improved after operation and none were worse. In order to assess our outcomes we used the duPont bunion rating score, which incorporates objective and subjective criteria. We had 5 excellent and 17 good results.

There were no fair or poor results.

Conclusion: Our proposed modified procedure is easy to perform and does not need any internal fixation device. The complications linked to the use of the hardware are removed. Our proposed procedure does not interfere with the shape or the length of the first metatarsal and does not preclude the possibility of further surgical correction.