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Introduction: The choice of surgical technique for high-grade spondylolisthesis (HGS) associated with lumbosacral kyphosis remains controversial. Are non-instrumented techniques still relevant, what with the multiplicity and modernity of patient-specific instrumentation?, Hypothesis: Our hypothesis was that a non-instrumented circumferential arthrodesis performed after a period of gradual reduction of HGS, associated with lumbosacral kyphosis, provided satisfactory long-term functional and radiographic results in children and adolescents while minimizing the risk of complications., Materials and Methods: Thirty-one L5-S1 HGS associated with a lumbosacral kyphosis operated by non-instrumented circumferential arthrodesis after a period of traction and suspension were included in our study. The first stage of this technique consisted of a gradual reduction using traction followed by immobilization in the corrected position. The second stage involved a posterior, followed by an anterior, surgical procedure and a spica cast immobilization for 4 months. The mean age at surgery was 13.9±2.3 years (6-18) and the mean follow-up was 10.3±4.5 years (2.1-17.8)., Results: The overall complication rate was 26% (n=8/31): 13% neurologic complications, 10% bone fusion defects and 3% skin complications. The reoperation rate was 13% (n=4/31). The mean ODI (/50) was 3±4.6 (0-22) and the SRS-30 126.7±15 (72-143). The Taillard index decreased by 25% (p<.001) and remained stable throughout the follow-up period (p=.65). The lumbosacral angle was corrected by 13.5% (p=.03) and the correction was maintained throughout the follow-up period (p=.71). At the last follow-up, the lumbosacral angle was significantly correlated with a low ODI score and a high SRS-30 score (p<.05)., Conclusion: Even though this technique achieved a smaller reduction of the lumbosacral angle, it reduced by at least a factor of three the incidence of neurologic complications and resulted in satisfactory functional outcomes when compared to instrumented and intraoperative correction series., Level of Evidence: IV., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Few published data are available on long-term outcomes of anterior spinal fusion for adolescent idiopathic scoliosis (AIS). The objective of this single-centre retrospective study was to assess clinical and radiological outcomes of one-stage anterior spinal fusion achieved using precontoured titanium anterior screw-plates., Hypothesis: Our hypothesis was that anterior instrumentation produced both good functional outcomes and good correction in the coronal and sagittal planes., Material and Methods: This procedure was performed in 111 patients between 1975 and 1993. Among them, those who underwent a comprehensive evaluation at least 15 years later were included. The SRS-30 questionnaire and Oswestry Disability Index (ODI) were used to assess functional outcomes. Radiographic outcomes were evaluated on antero-posterior and lateral full-spine radiographs obtained pre-operatively, post-operatively, and at last follow-up., Results: The study included 35 patients, who were re-evaluated after a mean of 21 years (15-31 years). Mean pre-operative Cobb's angle was 44°, mean age at surgery was 14.7 years, mean SRS-30 score was 3.65/5, and mean ODI was 14.9%. At last follow-up, mean Cobb's angle was 14.7° and 25 patients exhibited coronal misalignment with a mean deviation of 12mm. In the sagittal plane, the mean sagittal vertical axis (SVA) measured using the C7 plumb line was -28mm, with 8mm of anterior translation compared to the post-operative value (36mm). The functional outcome assessed using the SRS-30 score correlated significantly with pelvic tilt and anterior SVA translation., Conclusion: Anterior spinal fusion produces good long-term functional outcomes in AIS. Correction is both satisfactory and sustained. Anterior SVA translation over time may be associated with better functional outcomes., Level of Evidence: IV (retrospective study)., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children. The hip is usually affected later, and its involvement is the most common cause of disability in JIA. Failure of medical and preventive treatment, significant joint destruction, or multiarticular involvement may necessitate total hip arthroplasty (THA) to restore good function. Related clinical trials show initially good THA results in most of the series, but long-term outcomes are uncertain due to a significant arthroplasty loosening rate in the initial years, particularly with cemented stems. The authors report the results of 62 noncemented THAs in 34 children with JIA after an average follow-up of 6 years (range 3-13). Mean age at surgery was 18.3 years (range 11.8-31) and 14 of the 34 children had active disease. Clinical results were good for hip function but less for global function. There were no infections. Two acetabular cups early in the series failed due to poor primary fixation and had to be revised. Survivorship analysis was performed with the Kaplan-Meier method. At 13 years, the survival rate was 100% for the femoral component and 90.1% for the acetabular component.

Purpose of the Study: A survey was conducted at the Necker-Enfants-Malades Hospital in Paris and the Roscoff Helio-Marin Center in Roscoff, France to document results of posterior spinal fusion for scoliosis associated with osteogenesis imperfecta., Material and Methods: The cases of 27 patients who underwent posterior spinal fusion and Harrington (n = 2) or CD (n = 23) instrumentation performed by one senior orthopedic surgeon were reviewed. Two patients had posterior arthrodesis without instrumentation and were left in halo-traction together with a plaster cast until bone healing was achieved., Results: The series included eleven males and sixteen females. Mean age at fusion was 13 y 4 m. The average curvature before surgery was 77 degrees and the average correction was 37 degrees. Mean follow-up was six years. Minor complications due to halo pin infection or migration were observed in two patients and loss of correction with rod fracture in four., Discussion: Because of the risk of physical and respiratory incapacity, we believe that spinal surgery and arthrodesis for spinal deformity should be considered after a preparation period by halo-traction with exceptional precautions to correct major curves and prevent complications that could occur in patients with osteogenesis imperfecta. Correction and stabilization of the scoliotic spine in osteogenesis imperecta has yet to be definitively described since we have noticed that the site of deformation is transferred to the sacroiliac region once spinal fusion is achieved.

Purpose of the Study: Aneurysmal cyst is an uncommon benign primitive bone tumor generally observed in young subjects, in a spinal localization in 10% of the cases. We report the clinical, radiological, and therapeutic aspects of seven cases of aneurysmal cyst of the spine., Material and Methods: This series included seven children, mean age 11.7 years (range 8-14) who were followed for 9 years on the average (range 2-24 years). Findings were compared with reports in the literature., Results: Four cysts were located in the cervical spine (C1, C3, C4, C7), two in the thoracic spine (T4, T7) and one in the sacrum. Biopsy-resection was performed in six patients. The sacral cyst was treated by selective arterial embolization. Two complications were observed after surgical treatment. Bony filling of the lesion, evaluated by CT scan six months after surgery, was achieved in five cases, incomplete in two without recurrence of cystic cavities., Discussion and Conclusion: Aneurysmal bone cysts account for 15% of all primitive tumors of the spine. They are more frequent in the cervical and thoracic spine than in a lumbar or sacral localization. One vertebra is involved in most cases, generally the vertebral body and the posterior arch with an asymmetrical extension to one pedicle in some cases. Neurological complications of variable severity are frequent and can be improved by surgical removal of the tumor. CT scan and MRI are the best exams to analyze the spinal cyst, to show bony walls and liquid-liquid levels suggestive of aneurysmal bone cyst, to evaluate the tumor extension and to search for cord compression. When the CT scan and MRI show characteristic signs of aneurysmal bone cyst of the spine, we do not perform a biopsy systematically if complete removal of the tumor appears possible. Surgical removal with biopsy is the treatment of choice. Reconstruction and stabilization of the spine must be complete using bone graft with or without instrumentation. In case of medullary involvement, decompression must be performed rapidly with the most complete tumor removal as possible. Selective arterial embolization can be used in some localizations or as preparation to surgery. Radiotherapy is contraindicated in children because of the risk of radio-induced tumors.

We reviewed 5 cases of type I epiphyseal fracture with dislocation of the femoral head from the acetabulum in adolescent patients. All children had an open reduction and screw fixation. In all cases, the femoral head developed avascular necrosis. The clinical result after a mean of 3-9 years' follow-up was good according to the Merle d'Aubigné-Postel scale. Despite necrosis, 2 heads developed spherically after treatment: one which had a primary physeal resection and fixation, the other after an autogenous bone graft in the screw track following removal of the screw.

Acromicric dysplasia is a rare bone dysplasia characterised by short stature, short hands and feet, normal intelligence, mild facial dysmorphism, and characteristic x ray abnormalities of the hands. Only a very small number of children with this condition have been reported so far. Here we report on a series of 22 patients including 10 boys and 12 girls with acromicric dysplasia. Length was normal at birth and height fell progressively off the centiles postnatally. The mean adult height was 130 cm (133 cm in males, 129 cm in females). The hands, feet, and limbs were short and OFC was normal. Intelligence was normal and mild dysmorphic features were noted. Other occasional features included well developed muscles, a hoarse voice, generalised joint limitation in some patients, frequent ear, tracheal, and respiratory complication, and spine abnormalities. Long term follow up showed that facial dysmorphism was less obvious in adults and that carpal tunnel syndrome was frequent in older patients. Apart from short metacarpals and phalanges, internal notch of the second metacarpal, external notch of the fifth metacarpal, and internal notch of the femoral heads, there were no major x ray abnormalities. No major complications, such as cardiac disease or major orthopaedic problems, occurred in the course of the disease. The condition appeared to be sporadic in 16 cases but the observation of vertical transmission in three families was consistent with an autosomal dominant mode of inheritance.

During a period of 6 years to 11 years, the authors have been following six girls with scoliosis and treated with growth hormone (GH) for a growth insufficiency. The treatment with GH started after the discovery of the scoliosis for five patients. Three curve progressions have been observed, but always in the puberty period. Only one progression was noticed at the beginning of the GH treatment, but it was relieved with bracing. The results of this study do not permit one to conclude that a relation exists between GH treatment and scoliotic progression. This treatment is nevertheless not devoid of side effects, and a rigorous supervision is necessary.

A fracture dislocation of the upper thoracic spine with spinal cord injury is reported in a neonate. This rare injury is associated with attendant predisposing obstetric circumstances (breech transverse presentations, large baby size) that can alert clinicians of potential problems and aid in the diagnosis of neonatal hypotonia and paralysis.

Purpose of the Study: Congenital pseudarthrosis of the clavicle is rare, only 200 cases having been reported. Based on 25 personal cases and an overview of the literature, we try to explain the etiology of this condition and the different kinds of treatment., Material and Methods: A retrospective analysis was performed on twenty-five children (16 females, 9 males, mean age at the end of the follow up - 11.5 yrs) from three different centers. We assessed the outcome of surgical and nonsurgical procedures, based on pain, functional ability, cosmetic results, and x-ray examination., Results: A family background was noted in three children. The lesion always involved the right side. Twenty patients presented a bump over the middle third of the clavicle, thirteen a foreshortened shoulder girdle, three complained of discomfort. In two cases, palpation of the clavicular area was painful. No neurovascular compressive syndrome was reported. None of the patients complained of a decrease in the range of motion or in the strength of the upper limb. X-rays showed a middle third defect. In five cases we found abnormal first ribs. Seventeen patients underwent surgery, at a mean age of 6 years and 4 months. The procedure always included excision of the pseudarthrosis at both ends and internal fixation with a wire or a plate. In only eight cases a bone graft was used. Healing was achieved in fourteen patients. Three patients needed a second surgical procedure. In these 3 cases we had not used bone grafting. All patients had a normal range of shoulder motion, except a twelve year old girl who complained of discomfort of the right upper limb. The cosmetic result was good in eleven cases, one surgical wound was noted as hypertrophic, and one developed a keloid. An asymmetry of the trunk was still noted in seven cases. The x-rays showed symmetric clavicles in ten cases. Eight patients were treated conservatively. All of them had a normal range of motion of the shoulder, six had a good cosmetic result and two cases a poor one., Discussion: According to Alldred, the anomaly results from the failed coalescence of the two primary ossification centers of the clavicle. The overview of the literature and our findings (in one case) confirm that the cartilage which covers both ends of the bone is made of growth cartilage. However, the true mechanism of the nonunion is still unknown. The three familial cases of our work suggest a possible genetic transmission of the disease. The diagnosis is based on the following criteria: right side lesion, found in infancy, without previous fracture, increasing size with growth, without major functional consequences, without neurofibromatosis or cleidocranial dysostosis symptom. X-rays or histologic examination will confirm the diagnosis showing the usual findings described above. Complications of the pseudarthrosis of the clavicle are rare and late. Conservative management appears to give good results as seen with our eight patients. However surgical treatment ensures symmetrical shoulder girdles and good function with few complications. Therefore, we recommend performing an excision of the cartilaginous caps, followed by an iliac bone graft and an internal fixation with wire. Surgical management will be preferred in symptomatic patients, in the case of major or increasing deformity, or on parental request.

Purpose of the Study: MacFarland fracture is a joint fracture of the ankle in children. The fracture line passes through the medial part of the lower epiphyseal disk of the tibia. Prognosis is dominated by later risk of malalignment and osteoarthritis. MacFarland fracture usually occurs subsequent to adduction trauma. The aim of this study was to analyze prognosis in a retrospective series of children with MacFarland fractures., Material and Method: The series included 24 cases (14 boys and 10 girls, mean age at the time of trauma 12.7 years, age range 10-15 years). The fractures were classed into two groups according to the Salter and Harris classification for epiphyseal detachment: Salter 3 (n=4) and Salter 4 (n=20). Surgical treatment was given in 17 cases (11 screw fixations, 4 pin fixations and 2 other ostheosynthesis combinations). Orthopedic care was given in 7 cases (mean immobilization=40 days). All 24 children were followed for a mean 3 years 2 months (3 months=12 years). Three outcome categories were used: good (no pain, stiffness or malalignment), fair (pain and/or stiffness, no malalignment), and poor (malalignment)., Results: Overall results were good in 15 cases, fair in 2 and poor in 7 (29 p. 100). Ankle malalignments (7 cases) required surgical correction: epiphysiodesis for varus<5, supramalleolar tibial valgization osteotomy for varus > 5 degrees. After these procedures, outcome was good with a normally aligned painless ankle at 13 months follow-up. Among factors predictive of malalignment (poor outcome), power of the initial trauma (traffic or sports accident in 5 of the 7 poor outcomes), crush injury (medial metaphyseal comminution in two cases which led to varus ankle despite well conducted treatment), fracture type (7 malalignments among the Salter 4 fractures versus none among the Salter 3 fractures), initially defective reduction or osteosynthesis material passing through the epiphyseal disk leading to epiphysiodesis., Discussion: Careful radiologic and clinical surveillance is needed and should be continued to the end of growth (fusion of the tibial cartilage) in children with high risk fractures in order to detect epiphysiodesis early and avoid secondary malalignment. Surgical correction does remain possible and gives good results.

Eleven wrists with painful Madelung deformity in seven patients were corrected during adolescence by a closing wedge osteotomy of the radius and a shortening osteotomy of the ulna, with conservation of the distal radioulnar joint. At late follow-up (9.7 years) function was considerably improved. When the ulnar head was correctly relocated during operation, a new distal radioulnar space developed. Shortening of the ulna must be generous and combined with slight flexion at the osteotomy.

The authors report a case of reconstruction of a great toe in a young boy, following amputation proximal to the IP joint and exposure of the MP joint. A local flap was chosen for its lesser morbidity, and plantar skin was selected as optimal coverage for weight-bearing surfaces on the first ray. Very few local flaps fulfill these conditions. The Y-V technique of elongation of a vascular pedicle, first described by Martin in 1991, was used to bring a medial plantar flap to the toe, doubling its normal arc of rotation distally. Technical points are highlighted and outcome is reported at 18 months follow-up.

The authors report a series of 36 patients of Apert's Syndrome in whom a genetic analysis was performed. 2 major types of mutation were found (S252W and P253R). The correlation between the type of mutation and certain clinical abnormalities allowed validation of Upton's modification of Blauth's classification and also helped add a prognostic indicator for the intellectual development of the child. Thus, global treatment of the child should take into account not just the clinical abnormalities but also its intellectual prospects.

Fractures of the odontoid process are rare in children. We retrospectively reviewed 15 cases in children younger than 6 years, with an average follow-up of 4 years and 3 months. Eight of these patients had neurologic involvement; magnetic resonance imaging (MRI) changes were seen in the spinal cord at the cervicothoracic junction in six. This neurologic injury was thought to be due to the major anterior displacement of the upper spine, causing spinal cord stretch at the spinal apex of the cervical and thoracic spine. Eight patients secured in forward-facing car seats were injured as the result of motor vehicle accident. Conservatively treated fractures fused without problem. By contrast, the three cases operated on as the initial management of the fracture had complications postoperatively.

The purpose of this investigation was to determine whether induced micromovement during the elongation period could improve the consolidation of diaphyseal elongation obtained by callus distraction. Two series of paired rabbit hindlimbs were studied. The surgical procedure and the waiting period were identical. During elongation, one hindlimb was stimulated, and the other was the control. The consolidation period was 2 days. Reproducible tibial osteotomy and lengthening of the two tibiae was confirmed radiographically. The mineralized callus was quantified by dual-beam x-ray absorptiometry. The callus diameters were measured. Bones were axially compressed to failure. Callus volume, mineral quantity, mineral density, and resistance to failure were not different on the stimulated side compared with the unstimulated side, so micromovement applied during elongation had no effect on bone consolidation. For all tibiae, resistance to failure of the callus was significantly correlated to callus volume, to callus mineral content, and to callus mineral density.

We reviewed 19 children and adolescents with cervical spine congenital synostosis as in Klippel-Feil syndrome (KFS), with an average follow-up of 12.5 years. We paid particular attention to neurologic complications associated with cervical spine abnormalities. Five patients were affected by neurologic complications; four underwent a surgical procedure; and 14 had no neurologic finding. Two had hypermobility at one level, and one had hypermobility at two levels. We found that the more numerous the occipito-C1 abnormalities, the more significant the neurologic risk. In contrast, this risk was not related to the number of "mobile blocks" or to age. Various mechanisms of neural complications have been studied in the literature: medullary abnormality, spinal instability, narrowing of the cervical canal, and vascular dysfunction. Surgery is usually thought to be required in cases with neurologic complications. The indication for surgery is, however, less clear in cases of pure instability without neurologic involvement because surgery is likely to increase the future risks at mobile disks either above or below the fuse level. Careful clinical and radiologic observation is necessary in such patients. Magnetic resonance imaging (MRI) with lateral views in flexion and extension seem to be the best method for detecting impingement of the spine on the cord.

We observed 39 feet with a "too-long" anteromedial process of the calcaneus (TLAP) in 25 children and adolescents. The abnormality was diagnosed from symptoms (ankle sprains or persistent ankle or foot pain) in 33 cases. Six cases of TLAP were noted on radiographs taken of the patient's opposite, asymptomatic foot. Initial treatment by 3 weeks of strapping failed in seven of seven cases, and 3-6 weeks of primary plaster immobilization failed in 10 of 25 feet. Primary immobilization treatment failed in 17 of 33 symptomatic feet. Resection of the TLAP provided good results in 14 of 15 feet when used as a secondary procedure after failure of immobilization treatment and in one foot in which it was used as primary treatment. We believe that this abnormality is an anatomic variant that becomes symptomatic because of inversion stress with impingement of the abnormally long process between talus and cuboid.

Femoral and tibial growth was studied in 6 children undergoing a femoral lengthening and 28 children a tibial lengthening. Growth of both femurs and tibiae was evaluated for 3 years both before and after the procedure. No significant growth disturbance was noted in femoral lengthenings of 14%. However, growth variations were constant after tibial lengthening of 18% on the average and could be correlated to the amount of lengthening. The consequences of these changes are limited in terms of final limb length because overgrowth of the femur often compensates for growth retardation of the tibia when tibial lengthening is less than 18%. Experimental and clinical studies assert that lengthenings of more than 30% can result in significant and definite growth retardation of the lengthened bone.

The authors report a retrospective series of 37 patients (49 forearms) with congenital radioulnar synostosis followed and treated at Raymond Poincaré University Hospital. This disease is rare, but much more frequent than post-traumatic or humeroradial synostosis. A genetic factor was incriminated in 25% of patients. The clinical study was based on 31 files (40 forearms) with a subjective finding of hypermobility of the wrist in all patients. Shortening of the ipsilateral upper extremity < or = 2 cm was also observed in one third of patients, and a defect of elbow extension was observed in 35%. The radiological study, conducted on 30 files (38 forearms), confirmed the existence of several degrees of fusion within the synostosis and revealed an associated radiological abnormality in 92% of cases. The only valid correlation revealed was between the degree of fusion of the synostosis and the presence of a morphological abnormality of the radial head (r = 0.87), hence the proposal of a new radiological classification essentially based on this element. Functional adaptation was excellent in the majority of cases. The authors propose two main indications for surgery: hyperpronation > or = 90 degrees and bilateral synostosis; in both cases, the disability must be very severe. The operative technique used appeared to be very well adapted to this disease: "reed" radial osteotomy and transverse ulnar osteotomy. No complications or relapses were observed in six operated patients with a mean follow-up of 10 years, with a mean loss of derotation of only 5 degrees.

Purpose of the Study: In 1983, we reported 5 cases of a type of tarsal abnormality which often went unrecognized in children and adolescents, the so-called "too long antero-medial process of the calcaneus" (TLAP). This report analyzes 59 such abnormalities observed in 37 children and adolescents. Treatment of the 48 symptomatic cases is presented., Material: A retrospective study was done on the files of all patients in whom oblique foot radiographs, CT scan or MRI of the foot showed an abnormal antero-medial process of the calcaneus. Of this group, patients were re-examined and radiographs of both feet (AP, lateral and oblique views) were obtained., Methods: Gender, age at occurrence of symptoms, diagnosis and follow-up, patient complaints and successive treatment were assessed. Final clinical results were graded according to patient's complaints of pain and functional limitation as well as clinical evaluation of subtalar motion., Results: Fifty-nine TLAPs have been found in 37 patients, 30 girls and 7 boys of 11.6 years on average at the first symptoms. Delay of diagnosis from onset of symptoms to final diagnosis averaged 2 years. First symptoms were so-called ankle sprains in 19 patients, ankle instability with tarsal pain in 17, pain and tarsal stiffness in 11, spastic flat foot in 1. In 11 patients, the abnormality was found on the opposite foot. In 2 patients, the TLAP was combined to a calcaneo-navicular bridge of the other foot. Eleven strapping managements resulted in 11 failures, 36 plaster immobilizations led to 12 good, 2 fair and 22 poor results; 25 resections gave 23 good, 1 fair and 1 poor result at a 4.6 years follow-up on average., Discussion: In some people, the antero-medial process of the calcaneus is elongated and becomes interposed between the head of the talus and the cuboïd, far enough to cause impingement on the navicular. Because of the elongation, supination produces a "nutcracker" phenomenon with compression of the process between the talus and the cuboïd; this may result in a chondral injury of the talus head at its inferior and lateral part which faced the TLAP. Authors suggest that calcaneo-navicular coalition and TLAP represent a spectrum of types of errors in embryologie mesenchymal formation with lack of normal joint formation of the tarsal ossicles during fetal life. Immobilization treatment as primary management was particularly unsuccessful in the group with recurrent ankle sprains and persistent pain. Process resection proved a highly successful technique in management of those patients who failed to achieve good results with plaster immobilization., Conclusion: The "too long antero-medial process of the calcaneus" should be considered when assessing possible causes of recurrent ankle sprain or persistent tarsal pain in adolescents. An oblique X-ray is usually satisfactory for diagnosis. In patients who failed a conservative management, resection of the process produced good results and painless, supple feet.

We studied vertebral growth after thoracic or lumbar fractures in 52 children followed up from the time of fracture until skeletal maturity. We identified pure anterior compression in 32, combined anterior and lateral compression in 11, and total vertical compression in nine. Six patients had no treatment, 42 had a conservative treatment, and four were operated on. In fractures with anterior compression < 10 degrees, no significant difference could be found between the group without treatment and the group with conservative treatment when the Risser sign was 0 or 1 at the time of injury. In such fractures with angles > 10 degrees, conservative treatment gave better results when the Risser sign at injury was < or = 2. Prolonged conservative treatment was not effective in children with a Risser sign of 3. The evolution of lateral compression seems to be related to the initial injury rather than to treatment. Vertical compression injuries were positively influenced by a conservative treatment when the Risser sign was < or = 2.

The purpose of this investigation was to determine whether induced micromovement could improve the consolidation of diaphyseal elongation by callus distraction. Two series of paired rabbit hindlimbs were studied. The surgical procedure, waiting period, and elongation period were identical. One hindlimb was then left under neutralization conditions, but the other limb was stimulated by axial micromovements. Reproducible tibial osteotomy and lengthening of the two tibiae were confirmed radiographically. The mineralized callus was quantified by dual-beam x-ray absorptiometry. The anteroposterior and lateral diameters of the callus were measured. A semiquantitative histologic study allowed the ratio between fibrous or cartilaginous callus or both and mineralized callus to be determined. Bones were axially compressed to failure. Callus volume, callus mineral content, callus mineral density, and mechanical forces required to failure were significantly superior on the stimulated side compared with the neutralized side, so micromovements applied after the end of elongation were beneficial for bone healing. Mechanical forces required to failure were significantly correlated to callus volume and callus mineral density.

The authors reviewed 70 femoral lengthenings performed for limb-length discrepancy in 66 children and adolescents using gradual incremental distraction. Nine were performed using the Judet lengthener and 61, the Orthofix external fixator. Etiology of the femoral shortening was congenital in 22, posttraumatic in 17, postinfection in 13, neurologic in 12, and miscellaneous in six. There were 83 complications, which were assessed as to their relation to the etiology of shortening, amount of lengthening, and age. The incidence of joint complications did not seem to be less than that previously encountered with rapid distraction methods of lengthening. Bony consolidation was achieved without additional surgery in 88% of cases. Delayed consolidation was most commonly encountered in children younger than 8 years old with congenitally short femora. The authors believe that good results can be obtained by incremental distraction by using uniplanar fixation by aggressive physical therapy, proper fixator application, and appropriate dynamization of the fixator.

Purpose of the Study: Results of femoral lengthening using callotasis method, with particular attention to the complications are presented., Material and Methods: 79 femoral lengthenings performed for limb length discrepancy in 75 children and adolescents were studied. Etiology of the femoral shortening was congenital in 23 cases, post-traumatic in 20, post-infection in 14, neurologic in 13, and miscellaneous in 9. Nine lengthenings were performed using the Judet lengthener and 70 using the Orthofix external fixator. We used gradual incremental distraction (callotasis)., Results: Average lengthening achieved was 52 mm (range: 35 to 85), which represented a 17.7 per cent increase in femoral length (range 7.6 per cent to 64 per cent). There were 87 complications, i.e. 110 per cent. Several complications were often encountered during one lengthening, thus, 23 lengthenings (30 per cent) were performed without any complication and 49 (62 per cent) without additional unpredicted operations or anesthesia. All these complications were studied according to the stage (intraoperative, elongation, consolidation and delayed) in which they occurred and to their severity. They were assessed to establish their relationship to etiology of shortening, amount of lengthening and age. Intraoperative complications were rare (2 cases). In the distraction period, joint complications are the most frequent (33 complications), involving the hip 22 times and the knee 11 times; 28 healed without any problems, 14 needed reoperation and 1 dislocation of the hip led to an avascular necrosis., Discussion: The incidence of joint complications did not seem to be less than that encountered with previous methods of lengthening. The author believes that systematic tenotomies performed in order to avoid such complications in congenital short femurs are abusive and have to be discussed case-by-case. Bony consolidation was achieved without additional surgery in 90 per cent of cases. Eight patients had delayed consolidation but did not require surgery. Complicated consolidation was most commonly encountered in children less than 8 years old with congenitally short femurs. The author compared healing time according to the type of dynamization. A significant improvement was found when using a silastic collar (33.3 days/cm) in place of classical dynamization (46.6 days/cm)., Conclusion: The author believes that good results can be obtained by incremental distraction using uniplanar fixation. Results could be improved by proper fixator application, aggressive physical therapy and well-thought dynamization of the fixator.