Aim

Synovial sarcoma (SS) is a malignant soft tissue sarcoma with a poor prognosis because of late local recurrence and distant metastases. To our knowledge, no studies have minimum follow-up of 10 years that evaluate long-term outcomes for survivors.

Introduction: Evaluation of acute hip pain in children can be challenging, because there are several diagnoses to consider. Most patients have a transient synovitis of the hip, which is a benign and self-limited condition. However, its similarities with other more serious disease make the diagnosis one of exclusion. In the Children’s Hospital of Geneva, children presenting with an acute hip pain are treated according to a specific screening protocol including blood sample with rheumatoid panel, hip ultrasound, and conventional X-rays. The objective of our study were to assess the efficacy of the screening protocol on the final diagnosis. We also provided a better characterization of transient synovitis of the hip.

Methods: We retrospectively reviewed the medical records of children who had the investigation’s protocol between 1999 and 2003.

Results: 269 medical records were reviewed comprising 66.2% of boys and 33.8% of girls, with a mean age of 5.5 years. Prior to presentation, 68.4% of children reported pain of < 24 hours in duration. Limp or refusal to bear weight was observed in all cases. According to the Kocher’s predictors of septic arthritis of the hip (fever, non weight-bearing, ESR > 40 mm/h, serum WBC count of > 12000 cells/mm3), 62% had zero predictor, 22% had one, 15% two, 1% three, and none four. A positive rheumatoid factor test was found in 18% of children, whereas 16% of patients had a positive antinuclear antibody test. During hospitalisation one child was diagnosed as having septic arthritis. The remaining patients were diagnosed by exclusion as having a transient synovitis of the hip since clinical follow-up was normal at 6 weeks.

Conclusion: Transient synovitis of the hip is a diagnosis of exclusion, and septic arthritis is the main condition to rule out. Using Kocher’s predictors of septic arthritis is useful for distinction between both conditions early at presentation. In our collective, only 3 patients with transient synovitis had a three of four predictors. Our study also showed that screening for a rheumatologic disease should not be done routinely at the first episode of hip pain. Indeed, positive tests were never confirmed with a clinical situation evocative of rheumatologic disease. More selective criteria should be used before doing a rheumatologic panel. Furthermore our work emphasizes the economical impact of a management of this frequent condition with less blood investigations.

Introduction: Mac Farland fracture is a joint fracture of the ankle in children, which involves the medial malleolus (Salter-Harris type III or IV) and is frequently associated with a fracture of the distal fibula. These injuries have a major risk of resulting in a medial epiphysiodesis bridge which, in turn, can lead to a varus deformity. As of today, recommended treatment for displacements wider than 2mm is open reduction with screw fixation. The aim of this study is to evaluate functional and radiological results of a new less invasive surgical procedure.

Materials and Methods: We retrospectively analyzed a case series of patients who suffered from a Mac Farland fracture and underwent percutaneous screw fixation with arthrographic control. Data collected for each child included age at diagnosis, gender, mechanism and side of injury, radiological Salter-Harris classification of medial and lateral malleolus fracture, size of the fracture line gap before and after treatment, and duration of cast immobilization. Results are given according to the classification by Gleizes (2000), based on clinical and radiological criteria: good, fair, and poor.

Results: There were twelve patients, five girls and seven boys, with a mean age of twelve years and six months (range: 10–15). Average follow-up was eighteen months (range: 9–57). Medial malleolus fracture was Salter-Harris type III in seven patients and type IV in five. The mean preoperative fracture line gap was 2.7mm (range: 2–4). All the patients underwent closed reduction and ankle arthrography to check for anatomical reposition. The fracture was then percutaneously fixed with two screws in nine patients and one screw in three. Duration of cast immobilization after surgery was forty-five days in average. At the time of last follow-up the functional and radiological results were good for all the patients according to Gleizes’ classification.

Conclusion: Closed reduction combined to ankle arthrography followed by percutaneous osteosynthesis is, in our opinion, an interesting less invasive surgical alternative to classic open reduction and internal fixation for displaced Mac Farland fractures.

Purpose: The immature skeleton demonstrates a remarkable capacity for correcting residual deformations after fracture. Classically, a residual angle of less than 25° can be tolerated for distal fractures of the forearm in children. The degree of remodelling depends on the distance between the fracture line and the epiphyseal line, the time remaining before closure of the growth cartilage, the residual angle after reduction, and is orientation in relation to the motion of the adjacent joint. The purpose of the present study was to better define the upper limit for acceptable deformation by age in order to determine when surgical correction is indicated.

Material and methods: We reviewed the radiography files of 106 children with one or two fractures of the distal third of the forearm who had required closed reduction and brachio-antebrachial cast immobilisation. We measured the angle of deformity on the AP and lateral views after reduction, at six weeks and at three, six, and twelve months after trauma. The series included 79 boys and 27 girls, mean age 8.5 years (range 2.5 – 15). Twenty-five fractures were epiphyseal fractures and 81 were metaphyseal fractures.

Results: Remodelling was nearly complete one year after fracture in most cases, especially in younger children and more distal fractures. Salter I or II fractures remodelled very rapidly, within four to five months of trauma. This remodelling was mainly achieved by apposition-resorption in the metaphyseal area by reorientation of the epiphyseal line. For the metaphyseal fractures, rate of remodelling was inversely proportional to the distance between the fracture line and the growth cartilage. Remodelling was greatly perturbed in case of open fracture requiring surgical reduction and in case of secondary infection.

Discussion and conclusion: These data show that posterior inclination can be tolerated up to 30° for children under eight years of age and up to 25° between eight and ten years and up to 20° at prepuberty. Knowledge of these limits for distal fractures of the forearm is important for proper management and can be helpful in reducing the number of primary or secondary reductions under general or locoregional anaesthesia.

A six-year-old girl sustained a Monteggia type-I equivalent fracture of the right forearm. We describe the method of treatment of this rare fracture and its outcome.

Purpose: The Less Invasive Stabilisation System (LISS) for fixation of the proximal femur is an automatic preformed fixator with three sizes. The self-perforating self-threading screws are locked into the plate fixator providing angular stability. Unlike conventional implants, the LISS plate is not applied directly to the bone, avoiding friction forces and periosteal damage. Precise adaptation of the implant to the form of the bone is not necessary. The system can also be easily and rapidly used as a “gliding” plate. After reduction via a proximal incision, the plate-fixator is inserted between the anterior tibial muscle and the periosteum and fixed with monocortical screws inserted percutaneously.

Material and methods: Between January 1999 and August 2000, we treated 18 multiple trauma patients with fractures of the proximal femur in 17 patients (nine men and eight women) using the LISS in a prospective multicentric study. Mean age was 50 years (20–89), median, 43 years). The AO classification of the fractures was four type A, four type B, and 13 type C. There were 14 open fractures. We used the LISS in one patient to stabilise a valgus osteotomy. One patient had a 41-C2.3 (Schatzker type VI) fracture with a compartment syndrome. Bone allographs were used in two cases. Clinical and radiographic follow-up data was collected at 6, 12, 24 and 48 weeks.

Results: Two foreign subjects with 41-A3 and 41-B1 fractures were lost to follow-up. For the other patients, bone healing was achieved between six and twelve weeks. Mean follow-up was ten months (three to twenty months). We had one complication, the compartment syndrome mentioned above, which healed without sequelae after fasciotomy and secondary thin skin graft. Joint motion was symmetrical and pain free in all patients three months after surgery. There were no nerve or vessel lesions secondary to epiperiosteal displacement of the fixator, and no case of infection or loosening. We did however observe secondary loss of reduction with development of minimal varus in three patients with complex fractures.

Conclusions: These preliminary results with the LISS demonstrate its usefulness as an alternative to conventional fixation systems. It is undoubtedly a most useful method for intra-articular and metaphyseal fractures with diaphyseal fracture lines and for fractures with two levels. Complications appear to depend on the type of fracture and the quality of the reduction, as with other types of fixators.

Purpose: We reviewed major amputations of the lower limbs in geriatric patients.

Material and method: This retrospective study was conducted in patient treated between January 1990 and December 1999. A total of 265 amputations in 209 patients, including 24 revisions and 32 bilateral amputations, were included in the study. Inclusion criteria were the major nature of the amputation requiring prosthetic fitting and patient age (greater than 65 years).

Results: The incidence of amputation in our geriatric population was 4 per 10 000. Mean age at amputation was 78 ± 7.5 years. Mean follow-up was 27.8 months. Tibial amputations predominated (123/264, 46.4%). Aetiology factors were basically diabetes mellitus (99/209, 47.4%), and atherosclerosis (85/209, 40.7%). Overall survival at one year was 61.7%, 47.9% at two years and 13.7% at ten years. Survival was better for tibial amputations (p = 0.023). Analysis of 12 comorbiditties revealed that amputated patients had significantly higher mortality when they also had heart failure (p = 0.001), dialysis (p = 0.001), rhythm disorders (p = 0.003), dementia (p = 0.008). Rhythm disorders (p = 0.01) and dementia (p = à.02) usually predicted a femoral level of amputation. The number of surgical revisions required for amputation at a higher level was 9.1% (24/265). Amputations of the contralateral limb were required in 34/209 patients (16.3%) after a mean delay of 19.7 months. Half of our patients were fitted with a prosthesis (53.6%, 112/209).

Discussion: We did not find any predominant aetiological factors by level of amputation. Statistical analysis demonstrated that survival depended on the low level of the amputation. Preservation of the knee was an important factor not only for rehabilitation but also for mortality. Survival after femoral amputation and after desarticulation of the knee was the same. Prosthesis fitting was difficult at the femoral level. Mortality depends on four basic comorbidities, heart failure, dialysis, rhythm disorders and dementia. Addition of comorbidities for a given patient has a significant effect and is not compatible with survival greater than five years.

Two neonates, treated by the Pavlik harness for congenital dislocation of the hip, developed inferior dislocation due to excessive hip flexion. Early recognition of the complication and diminution of the angle of flexion gave a stable relocation of the hip in both patients.

Instability of the knee is frequently found in association with congenital leg-length discrepancy. We have studied six such patients clinically, radiologically and arthroscopically. Clinical signs of knee instability and significant radiological changes were present in all, and at arthroscopy the anterior cruciate ligament was completely absent in four patients and functionless in the other two. This deficiency appears to be a congenital condition which may predispose to meniscus injury or retropatellar pain; it may also lead to subluxation or dislocation of the knee during leg-lengthening procedures.