Search

Purpose of the Study: Retraction of the shoulder in internal rotation is observed in 25% of children with brachial plexus birth palsy (C5, C6 +/- C7). Early bone and joint deformities affecting the glenohumeral joint are the consequences. The stiff internal rotation requires surgical release which can involve the capsule and ligaments, muscles, or both. Internal release can be combined with muscle transfer to improve active external rotation. We report the results obtained with arthroscopic anterior capsular release combined with latissimus dorsi transfer., Material and Methods: From 1999 through 2006, fourteen children with a stiff shoulder in internal rotation secondary to brachial plexus birth palsy were managed in our unit. All had recovered biceps function six months after surgery. The glenohumeral dysplasia was analyzed on the preoperative magnetic resonance imaging. Pre- and postoperative passive external rotation (RE) were measured with the arm along the body and at 90 degrees elbow flexion. Internal rotation was measured using the Mallet score (hand-back test). Combined active abduction antepulsion was measured when the child was playing. Mean age at surgery was three years six months. Arthroscopic internal release was performed for eight children. All had an associated latissimus dorsi transfer., Results: Among the 14 children managed in the unit, arthrolysis was not be performed in six, either because of the lack of an adequate electrode (two patients) or because the child presented posterior glenohumeral dislocation making it impossible to introduce the optic channel (four patients). Arthroscopic anterior release was performed for the eight other patients. These eight patients were reviewed at a mean three-year follow-up. Passive external rotation was improved, with a mean gain of 60 degrees with no recovery of passive internal rotation. The abduction antepulsion movement was also improved, mean gain 90 degrees ., Discussion: A stiff shoulder in internal rotation can develop during the first two years of life. Several techniques have been proposed for internal release. The origin of the progressive limitation of passive external rotation remains a subject of debate. Is it due to retraction of the internal rotators, or to capsule-ligament retraction, or both? In 1992, Harryman et al. demonstrated the role of the capsule and the coracohumeral ligament in limiting external rotation. Consequently, we have opted for early release (less than two years of age) using an arthroscopic method limited to the capsule and ligaments. Our results for passive external rotation are comparable to those reported by others. However, this technique enables preserved mobility for internal rotation., Conclusion: Arthroscopic anterior release limited to the capsule and the ligaments is an effective, minimally invasive technique. Leaving the internal rotator muscles intact preserves internal rotation of the shoulder and reduces the risk of anterior instability.

Certain authors have proposed percutaneous neurolysis of Morton's neuroma. We conducted a human anatomy study to assess the reliability and the iatrogenic effect of percutaneous section of the ligament. Percutaneous section of the inter-metatarsal ligament was performed on 16 fresh cadaver specimens via a dorsal approach. The plantar dissection demonstrated that the section was not complete, without associated lesion, in only six cases. Analyzing these failures, we determined the necessary procedure for correct section.

Purpose of the Study: The vascularized fibular graft is a widely used technique for the reconstruction of long bone defects after tumor resection. Complications are not uncommon despite the presence of a good vascular supply. We report our experience with long bone reconstructions in children and adolescents after resection of primary malignant bone tumors., Material and Methods: This retrospective analysis included thirteen patients aged 4-17 years (mean age 12 years). Preoperatively, the pathological diagnosis was Ewing tumor (n=7), osteogenic sarcoma (n=5), neuroepithelioma (n=1). All patients except one were given chemotherapy preoperatively and postoperatively and four received adjuvant radiotherapy. Tumor resection created a gap (n=8) or involved resection-arthrodesis (n=5, three knees, one ankle, one elbow). All reconstructions used a vascularized fibular flap with a complementary corticocancellous autograft for seven., Results: Complete carcinological resection was achieved in all cases. Mean follow-up was 50 months (range 12-144 months). There were no cases of local recurrence. Three patients presented lung metastasis; two patients died. Eleven of the twelve patients who underwent tumor resection involving the lower limb were able to walk with full weight bearing at 13.9 months (range 841 months), half of them without any supportive device. The MSTS score was 21/30 (range 7-29). Both ends healed for eleven of thirteen grafts. Outcome was good in four cases at 7.7 months (range 6-11), fair in seven (with 1-5 complementary procedures) at 14.8 months (range 10-45) and poor in two (nonunion at last follow-up). Among the fibular grafts which healed, primary healing of the distal end was noted in all cases, but not for the proximal end. Significant transplant hypertrophy was noted in 62% of patients, measured at mean 77.1% (range 25-128%). Complications were: skin necrosis (n=2), nonunion (n=4, three aseptic and one septic), disassembly (n=3 with two transplant fractures), and spontaneous fracture which healed (n=5, all but one treated orthopedically). There were four donor site complications: retraction of the hallux flexor (n=3), regressive paresia of the common fibular nerve (n=1)., Discussion: The rate of healing in this series was similar to earlier reports. Healing was always achieved for the distal focus but not for the proximal focus which receives its blood supply from a branch of the anterior tibial artery which is not harvested. The defective blood supply can thus hinder bone healing. It is necessary to spare the proximal quarter of the fibula or harvest a bipediculated graft. The rate of graft hypertrophy was also similar, as was the rate of complications. The MSTS score was lower due to the poor results obtained with resection-arthrodesis of the knee joint. Graft fractures and aseptic nonunion are the most common complications but septic complications are more serious and can threaten graft survival. Complications at the donor site are exceptional., Conclusion: Long bone reconstruction using an autologous vascularized fibular graft is a reliable technique providing satisfactory functional results. Complications can be prevented by making solid fixation and using a corticocancellous graft creating a favorable osteoinducing environment. A massive allograft is another solution providing good immediate mechanical stability.

Chronic osteitis and squamous-cell carcinoma is a rare but classically described association. We report three cases of chronic tibial osteitis which developed open leg trauma. During the surveillance, after a latency period of several years, local signs developed leading to biopsy which provided the diagnosis of degenerative carcinomatosis. Search for locoregional extension or metastatic dissemination was negative. All three patients underwent amputation with good results. This small series, together with a review of the literature, enabled us to describe the principle epidemiological and diagnostic features, focusing on early signs. The appropriate management scheme remains to be determined although amputation, which some may consider as a failure, should not be postponed indefinitely.

Agenesia of the anterior cruciate ligament is a rare entity which is exceptionally symptomatic. We report a case observed in a 5-year-old boy who presented an unstable knee which was treated by Clocheville ligamentopàlasty. At five years followup, the functional outcome was satisfactory. The patient was symptom free and practiced sports activities. He did not develop any complications excepting flexion which was limited to 130 degrees . Magnetic resonance imaging demonstrated good integration of the autograft. Anterior instability in the child limits physical activity and can cause meniscal injury and early osteoarthritis. The Clocheville technique is adapted for pediatric patients with knee instability caused by a congenital defect or injury.

We report the case of traffic accident victim who suffered multiple injuries after being ejected from the vehicle. The patient suffered blunt trauma of the pelvis followed by acute ischemia of the lower limb. The initial work-up revealed minimally displaced fractures of the right and left obturator rings and the left sacral wing, as well as a non-displaced fracture of the anterior wall of the acetabulum. Computed tomography eliminated a compressive retroperitoneal hematoma. The mechanism of the injury was direct blunt trauma rupturing an atheroma plaque which led to thrombosis of the left common femoral artery. Thrombectomy three hours 30 minutes after onset of ischemia enabled complete sensorial and motor recovery. Awareness of this unusual type of injury can be helpful in conducting a rigorous physical examination to ensure rapid diagnosis and treatment.

Chondroblastoma is a rare benign bone tumor. Treatment currently consists of curettage and bone graft. Prognosis depends basically on a relatively high rate of recurrence, between 5 and 38%, sometimes with local seeding of soft tissues and joint space. Such recurrences require wide resection with arthrodesis or even amputation. A 13-year-old girl with a humeral head chondroblastoma as treated by curettage and iliac bone graft. Six months later, a recurrence occurred with extension into the rotator cuff and the metaphysis. Remission was achieved by extensive surgical resection and hemiarthroplasty. The second case was a 14-year-old boy with a chondroblastoma of the right talus. He was treated by curettage and packing with bone substitute. After 2 recurrences with soft tissue and intra-articular extension, we performed a wide resection with reconstruction using a vascularized fibular graft. Many other cases in the literature illustrate such complications. We tried to find factors predictive of recurrence. Recurrence is observed when curettage was incomplete or when tumor cells were disseminated during surgery. Chondroblastoma is a benign bone tumor, but prognosis depends on the rapidity and severity of recurrence. Curettage should be as complete as possible and care should be taken to avoid contaminating the operative field.