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Since two decades, corneal crosslinking (CXL) has been proposed as the sole therapeutic option to halt progression of keratoconus or other ectatic diseases. CXL aims at stiffening the cornea using a combination of ultraviolet-A light and a chromophore (vitamin B2, riboflavin), and has been proposed in various indications, from progressive ectatic diseases to corneal infection. Despite being in clinical use for many years, many controversies and discrepancies exist towards CXL procedure and its exact role is still under debate. We report an up-to-date review of the state of the art of CXL and describe the basic principles, the different existing CXL techniques reporting basic and clinical evidence, as well as the new perspectives and the possible future developments of the procedure.

International audience; IntroductionStanding radiographs allow analysis of spinal segments and their relative positioning. However, it requires a specific positioning influencing spinal alignment. Knowledge of trunk movements when walking is therefore an essential step to evaluate dynamic sagittal balance. Our objective was to define spinal junction kinematics and their correlations during gait in a healthy population.MethodThis is a prospective, single-center study. Between 2015 and 2017, 25 healthy volunteers were included. The measurements were taken in a motion analysis laboratory. Several kinematic parameters were studied, including spinal junction movements in the three planes and dynamic sagittal vertical axis (Dyn-SVA). Pearson correlation coefficients were calculated to determine the interactions between the spinal junctions.ResultsIn the sagittal plane, the average amplitude of variation of the dyn-SVA was 25.5 cm (SD = 8.9). The average range of motion of the lumbosacral and thoracolumbar junction was approximately 3°, they operated in anti-phase during the gait cycle and were strongly correlated (r = −0.5069, p = 0.01). In the transverse plane, the anti-rotation of the upper body relative to the pelvis was mainly ensured by the opposite movements of the lumbosacral and thoracolumbar junction (r = 0.5689, p = 0.003). In the frontal plane, the lateral inclination in the lumbar region was made in the opposite direction from the pelvis toward the carrying member.ConclusionAlthough there is substantial inter-subject variability, our study characterized the angular movements in the three planes of the different spinal junctions, of the pelvis and the lower limbs during a gait cycle in a healthy population.

PURPOSE: To evaluate and compare epithelial remodeling after standard corneal cross-linking (S-CXL) and iontophoresis-assisted CXL (I-CXL) in eyes with keratoconus by anterior segment optical coherence tomography (AS-OCT). METHODS: In this prospective, observational study, AS-OCT and corneal topography were performed before and 1, 3, and 6 months after surgery. Corneal pachymetry was performed and epithelial and stromal thicknesses (central and 16 points on the 6-mm central zone) and the maximum simulated keratometry value (Kmax) were measured. RESULTS: Two groups of 30 patients (60 eyes total) with progressive keratoconus underwent S-CXL or I-CXL. Before surgery, both groups of patients presented with an irregular epithelial thickness profile. At 6 months postoperatively, localized corneal epithelial thinning was observed in the superior ( P = .026), inferior ( P = .034), inferonasal ( P = .024), and nasal ( P = .035) areas at 3 mm and in the superior ( P = .039), nasal ( P = .043), and inferior ( P = .01) areas at 6 mm in the SCXL group. Localized corneal epithelial thinning was observed at 3 ( P = .04) and 6 ( P = .01) mm in the inferior area in the I-CXL group. No significant stromal changes were observed for either group. Kmax was stable in both groups at 6 months. CONCLUSIONS: Significant epithelial remodeling occurs after S-CXL, resulting in a thinner, more regular thickness profile than after I-CXL. Epithelial thickness profile measurements after I-CXL could be used as an adjunctive follow-up tool for monitoring the efficacy of CXL in progressive keratoconus. [ J Refract Surg. 2018;34(8):551–558.]

Summary Standard corneal collagen crosslinking (S-CXL) is a safe, approved procedure, but it may result in severe pain, early vision loss and possible complications, such as infectious or sterile keratitis , in some cases. We describe four cases of sterile infiltrates after uneventful S-CXL for keratoconus , from diagnosis to medical management with six months of follow-up, reporting their pathophysiological features, and comparing our findings with published reports. We discuss various possibilities for diagnosing sterile infiltration more rapidly. In terms of the pathophysiology of sterile infiltrate formation, we separated our patients into two types, one with sterile infiltrate from an antigen reaction and the other with sterile infiltrate due to excessive scarring. Early local steroid treatment resulted in a good visual outcome in our cases.

In adolescent idiopathic scoliosis (AIS), spinal deformity can be seen in the thoracic or in the lumbar area. Although differences according to curve location are well described on standard radiographs, dynamic consequences of such difference remain unclear. Our objective was to explore the differences in dynamic spinal balance according to curve location in AIS patients using gait analysis METHODS: We prospectively included 22 females with AIS planned for surgical correction (16.3 years old, 81% Risser ≥ 4). Patients were divided into two matched cohorts, according to major curve location [right thoracic (Lenke 1) or left lumbar (Lenke 5)]. Gait analysis was performed the day before surgery. Global balance was analyzed as the primary outcome. Local curves parameters (dynamic Cobb angles) were defined as the secondary outcome.In coronal plane, Lenke 5 patients had a left trunk shift, whereas trunk was shifted to the right in Lenke 1 patients (- 20.7 vs 6.3, p = 0.001). In the sagittal plane, the main difference between the two groups was T12 position that remained over the pelvis during gait in Lenke 5 patients, whereas it was anterior to the pelvis in Lenke 1 patients. In the transversal plane, Lenke 5 and Lenke 1 patients presented the same gait abnormalities, with a global trunk rotation to the left (- 4.8 vs - 7.6, p = 0,165).This is the first study to provide the results of a direct comparison between Lenke 1 and Lenke 5 patients during gait. Curve location influenced coronal and sagittal balance, but abnormalities of transversal trunk motion were the same, wherever the curve was located. These slides can be retrieved under Electronic Supplementary Material.

Background In spinal deformity surgery, iatrogenic spinal cord injury is the most feared complication. Intraoperative monitoring (IOM) of the spinal cord assesses its functional integrity and allows significant reduction of the rate of spinal cord injury. Hypothesis In case of severe IOM alert, lesional level diagnosis constitutes supplementary and useful information. Material and methods This study was retrospective and monocentric. In our institution, 1062 pediatric spinal deformity surgeries have been monitored since 2004. We review the records of the six patients who presented a severe and prolonged IOM alert with lesional level determination. Somatosensory evoked potentials (SSEP), neurogenic mixed evoked potentials (NMEP) and D-waves were performed. In cases of IOM alert, sequentially moving an epidural electrode along the spinal cord allows lesional level determination, using this electrode either for stimulation or recording. Results Six patients, aged 12 to 17 years, characterized by severe IOM alerts during spinal deformity surgery are reported. Postoperative neurological examination was normal for five out of six cases. For patient 2, lesional level diagnosis allowed to determine a bi-laminar claw between T2 and T3 as the etiology of IOM alert. This IOM alert was delayed in time, being detectable only 30 minutes after the placement of this claw. Postoperative neurological examination was normal. For patient 6, a Stagnara wake-up test demonstrated paraplegia. Lesional level was established. Following corrective surgical maneuvers, postoperative neurologic deficit was limited to a pyramidal syndrome in one lower limb. Postoperative MRI demonstrated a spinal cord lesion at the determined lesional level. Conclusion During an IOM alert, lesional level determination allows localization of spinal cord dysfunction. This data, obtainable whatever the IOM device, constitutes supplementary information in order to rapidly identify the etiology of IOM alert and thus to react in the most appropriate way. Level of evidence IV, retrospective study.

The treatment objectives in congenital pseudarthrosis of the tibia are bone consolidation and a restored lower-limb axis. They are difficult to achieve, and various surgical techniques have been described, with varying results in terms of bone consolidation and complications. The present study reports clinical and radiographic results in 3 patients managed by the same original technique of transplantar intramedullary nailing using a custom-made proximal locking nail, without surgical approach or resection of the pseudarthrosis site. Good assembly stability allowed immediate weight-bearing. The technique is relatively noninvasive, offering a first-line alternative in under-3 year-olds.

Spinal muscular atrophies (SMA type 1, 2, 3) present with various severities according to the motor semeiology related to lesions of the peripheral nervous system (lesions of the anterior horn cells motoneuron or even brain stem). Early motor deficiency causes skeletal deformities responsible for the alteration or even absence of motor skills acquisition. The management of these patients involves several practitioners: pediatric neurologist, pediatric pneumologist, physical medicine and rehabilitation therapist, pediatric orthopedic surgeon, psychologist, physiotherapist, etc. Therefore, this multidisciplinary management must take place in a reference center. This has allowed for improvement of the natural history of SMA. Despite the severity of clinical presentation, especially in SMA type 1 or 2, the functional aspect is always to be taken into account in the first instance. Furthermore, the natural history of the disease is currently being modified by the emergence of innovative therapies that will change the evolution of the disease and its management. Indeed, current treatment objectives are the comfort of installation and the fight against neuro-orthopedic degradation. Although the rise in the number of innovative therapies has led to increased expectancies, such as motor function improvement, practitioners should be aware that these innovative treatments should be balanced against child development and the disease's natural history. Scoliosis surgery is almost systematic in SMA type 2 because of trunk muscular deficiency, especially intercostal muscle insufficiency, and spino-pelvic complex disorder. However, surgical techniques have evolved to become less invasive and more growth friendly in order to follow child development. The final goal of surgery in SMA patients is to obtain a 3-dimensional deformity correction along with a spino-pelvic realignment in order to allow for a comfortable seated position, which is the position of function in these patients, and to allow for better ventilation. Faced with this global approach and innovative therapies, global assessment is warranted not solely in an isolated manner, as is usually the case during hospital stays with traditional scales, but rather during daily activities. This is the case of daily monitoring, which allows for motor skill and activity assessments throughout the day. The principle is to characterize, according to SMA type and treatment, the activity type (standing, seated, walking), duration, intensity and frequency. The ultimate goal would be to identify the variety and occurrence of motor activities, and finally to clarify if the different treatments, including innovative therapies, lead to functional improvement in these patients. © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.

In the last few years several reports stressed the importance of sagittal alignment in adolescent idiopathic scoliosis (AIS) patients. It was recently reported that T1 slope, defined as the angle between the superior endplate of T1 and the horizontal, correlates strongly with overall sagittal parameters. The aim of this study was to assess the impact of T1 parameters (T1-slope and T1-tilt) on sagittal alignment of AIS hypokyphotic patients preoperatively and postoperatively. Twenty-nine AIS patients with

IntroductionTo date there is no consensus on therapeutic indications in adolescent idiopathic scoliosis (AIS) with curvature between 30° and 60° at the end of growth.ObjectiveThe objective of this study was to assess outcome in patients with moderate AIS.Material and methodsA multicenter retrospective study was conducted. Inclusion criteria were: Cobb angle, 30–60° at end of growth; and follow-up > 20 years. The data collected were angular values in adolescence and at last follow-up, and quality of life scores at follow-up.ResultsA total of 258 patients were enrolled: 100 operated on in adolescence, 116 never operated on, and 42 operated on in adulthood. Mean follow-up was 27.8 years. Cobb angle progression significantly differed between the 3 groups: 3.2° versus 8.8° versus 23.6°, respectively; P 35° (OR=4.278, P=0.002). There were no significant differences in quality of life scores.DiscussionPatients operated on in adolescence showed little radiological progression, demonstrating the efficacy of surgical treatment for curvature greater than 50°. Curvature greater than 40° was progressive and may require surgery in adulthood. Lumbar scoliosis showed greater potential progression than thoracic scoliosis in adulthood, requiring fusion as of 35° angulation.Level of evidenceIV, retrospective study.

Infectious keratitis are a frequent cause of ocular morbidity. Today, new treatments are necessary to combat the emergence of antibiotic resistant germs. Corneal collagen cross-linking has been suggested to treat corneal infectious (PACK-CXL). Its action would be both antimicrobial and protective for the cornea, increasing its biochemical resistence to proteolytic enzymes. In vivo, PACK-CXL might demonstrate good efficacy against bacterial keratitis, contrary to herpetic keratitis for which it is contraindicated. For fungal or amoebic keratitis, results are uncertain regarding its safety and efficacy. The purpose of this paper is to clarify the use of corneal collagen cross-linking to treat infectious keratitis.

Thoracic adolescent idiopathic scoliosis (AIS) curves (Lenke 1–4) are often characterized by hypokyphosis. Sagittal alignment remains challenging to correct, even with recent posterior segmental instrumentation. Some authors recommend anterior endoscopic release (AER) to reduce anterior column height, and facilitate thoracic kyphosis correction. The aim of this study was to assess the contribution of AER to sagittal correction in hypokyphotic AIS. Fifty-six hypokyphotic (T4T12

Objective In hemiplegic children the appearance of equinovarus is correlated with premature electromyography (EMG) activity of the gastrocnemius medialis (GM) prior to initial contact. The goal was to analyze the onset of EMG activation in the GM and, more particularly, the peroneus longus (PL) in cases of equinovarus: is PL activity likewise premature? Material and methods As 15 hemiplegic children (age 5 years ± 1.5) with equinovarus walked, their PL and GM EMG activity was being recorded. The latter was normalized in terms of gait cycle percentage (0–100%) and detected through semi-automatic selection with activation threshold set at 20 μV. A paired t-test compared activation onset of the PL versus the GM muscles. Results As regards the healthy limb, activity onset of the GM (+14.55%) and the PL (+19.2%) muscles occurred only during the ST. In cases of equinovarus, activation of the GM (−5.2%) and the PL (−6.1%) occurred during the SW and was premature. For each muscle, comparison between the healthy and the hemiplegic side was highly significant (P Conclusion Premature PL and GM EMG activity preceding initial contact corresponds not to a disorder secondary to imbalance but rather, more probably, to motor command dysfunction. While the PL consequently contributes to equinus deformity, its possible role in varus genesis is less evident. EMG study needs to be completed by comparing PL and tibialis posterior strength while taking foot bone morphology into full account.

The best method for stabilising supracondylar humeral fractures (SHFs) in children remains unclear. The objective of this study was to compare the outcomes of five different fixation methods for SHFs in children.Differences in intra-operative and short-term post-operative parameters can be demonstrated across different fixation methods for SHFs in children.We reviewed the medical files of paediatric patients managed at our centre between 2006 and 2016 for SHF with major displacement (type 3 or 4 in the Lagrange-Rigault classification). Clinical and radiological parameters collected post-operatively and at last follow-up included Baumann's angle, anteversion of the distal humeral epiphysis, and operative time. Over the 11-year study period, 251 patients were included; mean age was 6.4 years and mean follow-up 4.7 months. The five fixation methods used were elastic stable intra-medullary nailing (ESIN, n=16), two pins in an X configuration (n=33), two lateral pins and one medial pin (n=144), two lateral pins (n=33), and three lateral pins (n=25). A minimally invasive 2-cm approach was used to insert the medial pins. Immediate instability of the fixation was considered in patients with an at least 15° deficit in Baumann's angle or anteversion, or with rotational malalignment, on the radiographs taken on day 1. Outcomes were analysed in each of the five internal fixation groups.Immediate instability showed no significant differences across the five groups. Operative time was significantly shorter with two lateral pins (33min, P=0.046). Time to hardware removal was longer in the ESIN group (54 days, P=0.03). Use of a medial pin was associated with a lower risk of secondary displacement (2.0% vs. 8.6%, P=0.04) but did not affect the risk of nerve injury (4% vs. 3%, P=0.86).This is one of the largest retrospective cohort studies of outcomes according to the fixation technique used to treat SHFs in children. Adding a medial pin through a minimally invasive approach is associated with a longer operative time but limits the risk of secondary displacement without increasing the frequency of iatrogenic nerve injury and improves fracture site stability. Use of a medial pin therefore deserves to be considered in paediatric SHFs.IV, retrospective cohort study.

International audience; Pediatric orthopedic surgery in humanitarian aid is conducted mainly in cooperation with emerging countries. Each mission is different, and depends on numerous parameters such as the country, the frequency of such missions, the pathologies encountered, the local structure and team, and the non-governmental organization (NGO) involved. Pathologies vary in etiology (tuberculosis, poliomyelitis) and severity. Each mission requires the presence of an experienced surgeon. Working conditions are often rudimentary. Surgical indications should be restricted to procedures that are going to be effective, with minimal postoperative complications, without any surgical "acrobatics". Teaching should be in association with the local university, and adapted to local needs. Mission objectives need to be realistic. Surgical indications should be adapted to local conditions, and the surgeon needs to be able to say "no" to procedures involving undue risk. The surgeon on mission should cooperate with local teams and be able to adapt to unusual situations. Assessment of results is essential to improving efficacy and evaluating the success of the mission.

To compare the efficacy, safety, and microstructural corneal changes during 2 years after conventional corneal collagen cross-linking (C-CXL) and transepithelial corneal CXL by iontophoresis (I-CXL) for keratoconus.Eighty eyes of 80 patients with progressive keratoconus were treated by C-CXL (n = 40) or I-CXL (n = 40). Patients were investigated before surgery and 1, 3, 6, 12, and 24 months after treatment. We measured central corneal thickness and maximal simulated keratometry values (Kmax) and performed specular microscopy and in vivo confocal microscopy at each time point. The demarcation line was assessed 1 month after treatment.Kmax remained stable after I-CXL during the entire study period (P = 0.56), whereas the average keratometry increased by 0.2 diopter (50.9 ± 5.6-51.1 ± 5.2). Kmax significantly decreased 1 (P = 0.02) to 2 years (P0.01) after C-CXL, with an average decrease of 1.1 diopters (49.9 ± 4.5-48.8 ± 4.2). The failure rate of I-CXL was 20% and that of C-CXL 7.5%. The demarcation line was superficially visible in 35% of cases after I-CXL compared with 95% of cases after C-CXL. Endothelial cell density and central corneal thickness remained stable during the entire study period. The change in Kmax 2 years after C-CXL and I-CXL and the preoperative Kmax were negatively correlated (r = 0.14, P = 0.013, and r = 0.17, P = 0.007, respectively).I-CXL halted progression of keratoconus less efficiently than did C-CXL after 2 years of follow-up. Longer prospective studies are still needed to ensure I-CXL efficacy.

Proximal junctional kyphosis (PJK) is a frequent proximal adjacent segment disease following spinal fusion in adolescent idiopathic scoliosis (AIS) and its rate has been estimated to 28% in the literature. The etiology is multifactorial, and risk factors associated with PJK are controversial. The aim of this study was to demonstrate that the disruption of muscular and bony tissue above the upper instrumented vertebra (UIV) during surgery does not increase the rate of PJK in patients undergoing posterior fusion for adolescent idiopathic scoliosis. 50 patients with AIS operated between June 2014 and January 2016 were included. Every patient underwent a long posterior spine arthrodesis with a hybrid construct (proximal lamino-laminar claw, thoracic sublaminar bands and lumbar screws). The dissection of posterior elements above the UIV was necessary for the placement of proximal anchors. Radiographic analysis including proximal junctional angle, spino-pelvic parameters (cervical lordosis, thoracic kyphosis TK, lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope) and sagittal vertical axis were collected preoperatively and postoperatively at the last control. The numbers of fused levels, locations of upper instrumented vertebra, locations of lower instrumented vertebra, length of fusion segments were also recorded. Multiple odd ratios and other statistical analysis were performed to evaluate the relation between PJK and the potential risk factors. There were 43 females and 7 males with a mean age of 14.8 years at surgery. PJK occurred in 5 out of 50 cases with an incidence of 10%. The mean follow-up was 18 months. There was no significant difference in gender (OR 1.36, p = 0.8), decrease of TK (OR 1.63, p = 0 0.69), location of UIV (OR 2.25, p = 0.4), LIV (OR 2, p = 0.55), and SVA change (OR 1.63, p = 0.46). The disruption of ligamentous and bony tissue proximal to the UIV during the surgery does not increase the rate of PJK. Level of evidence IV.

International audience; Tropheryma whipplei was detected in preliminary studies in faeces of young children with diarrhoea and also in faeces of asymptomatic persons, not only in Europe but also in Africa. In this study, the link between this bacterium and the presence of acute diarrhoea was evaluated in a large group of children. From December 2009 to January 2013, rectal swabs collected from 3796 children in the emergency departments of university hospitals in Marseille, France, were analysed: 555 children (245 female and 310 male, from 6 days to 6 years old) with acute diarrhoea defined as at least three loose stools per day for

The free vascularised fibular flap (FVFF) is widely used to treat bone defects, although it must be harvested from a healthy site. The objective of this study was to assess clinical morbidity and radiological changes at the FVFF donor site in children.Distal fibular stabilisation using a tibial strut decreases the prevalence of valgus ankle deformity.Thirty-one children managed at two centres between 1994 and 2014 were included. Mean age was 8.9 years (range, 2-14 years) and mean follow-up was 6.6 years (range, 2-21 years). Early and delayed complications were evaluated.Of the 17 early complications, 82.4% resolved fully within 7 months. Valgus ankle deformity developed in 6 (19.4%) patients. Age-residual fibula index under 16 was not significantly associated with valgus ankle deformity, although the P-value was borderline (P0.058). Residual distal fibula length did not predict valgus ankle deformity. Three techniques were used for fibular reconstruction: syndesmotic screw, tibial strut, and both. None of these techniques prevented the occurrence of valgus ankle deformity.Clinical donor-site morbidity after FVFF harvesting, although noticeable, usually resolved promptly. Taken alone, an age-residual fibula index under 16 did not predict valgus ankle deformity. We recommend a distal tibio-fibular quadricortical syndesmotic screw or combined syndesmotic screw-tibial strut fixation to prevent valgus ankle deformity, which is common when a tibial strut is used alone.IV.

Surgical adolescent idiopathic scoliosis (AIS) management can be associated with loss of thoracic kyphosis and a secondary loss of lumbar lordosis leading to iatrogenic flatback. Such conditions are associated with poorer clinical outcomes during adulthood. The aim of this study was to evaluate sagittal plane reciprocal changes after posterior spinal fusion in the setting of AIS. Thirty consecutive adolescents (mean age 14.6 years) with AIS Lenke 1, 2 or 3 were included in this retrospective study with 2 year follow-up. Full-spine standing coronal and lateral radiographs were obtained preoperatively, at 3 and 24 months postoperatively. Coronal Cobb angle, thoracic kyphosis (TK) and lumbar lordosis (LL) were measured. Surgical procedure was similar in all the cases, with use of pedicular screws between T11 and the lowest instrumented vertebra (≥L2), sublaminar hooks applied in compression at the upper thoracic level and sub-laminar bands and clamps in the concavity of the deformity. Statistical analysis was done using t test and Pearson correlation coefficient. Between preoperative and last follow-up evaluations a significant reduction of Cobb angle was observed (53.6° vs. 17.2°, p

Summary Study objectives Describing and assessing of a new surgical procedure to achieve circumferential fusion and translumbosacral fixation using a custom-made canulated screw. Patients and methods Seven patients aged 13–18 years old underwent surgery with this technique (mean age: 15). All patients had high-grade spondylolisthesis (Meyerding stage III or IV). There were five girls and two boys. A posterior surgical approach alone was used in all cases. The posterior neural arch of L5 was removed and a sacral laminectomy, extending to S2, was performed. Sacral nerve roots S2 and S3 were carefully dissected and transposed. A K-wire was placed medially across the vertebrae from the posterior edge of S2 extending to the anterosuperior corner of L5. Fluroscopic perioperative fluroscopic control confirmed correct K-wire placement. The custom-made 10 mm diameter canulated screw was then inserted along the K-wire as a guide. Screw fixation was obtained by placing a specific large diameter screw head to obtain compression by a lag screw effect. Once fixation was obtained, the sacral dome was excised and interbody fusion was performed (tricorticocancellous graft on each side of the screw). Additional bilateral posterolateral fusion was then performed. A half body custom fit thoracolumbar orthosis brace was prescribed 3 months postoperatively, followed by a Lombostat flexible lumbar support for an additional 3 months period. Results One neurological complication occurred. A dural tear occurred during dissection requiring simple repair. All of the patients were on their feet on the fifth postoperative day and began walking. The half bodybrace was worn for 4 months in four patients and 2 months in the three others. At final follow-up patients had no residual pain. Discussion The lumbar spine in children with high-grade spondylolisthesis adapts to the new mechanical conditions after surgery. Therefore the principal goal of treatment is to obtain stable osseous fusion. Our treatment philosophy is based on the concept of a dual instability. We believe that a general instability exists which causes the development of spondylolisthesis; this must be respected by not attempting to correct the displacement beyond what can be obtained on the operating table with complete muscle release. The other, locoregional instability, must be stabilized during circumferential fusion. The custom-made, 10 mm screw has been shown to be effective in neutralizing the mechanical stress during circumferential fusion with a posterior approach alone, thus avoiding the risks of an anterior approach. Long-term results show that the preoperative posture is not the sole mechanical determinant in children and adolescents but that this posture is largely a reaction to pain. Level of evidence Level IV. Retrospective study.

Objectives Treatment complexity of cerebral palsy (CP) patients imposes outcome evaluation studies, which may include objective technical analysis and more subjective functional evaluation. The Edinburgh Gait Score (EGS) was proposed as an additive or alternative when complex instrumented three-dimensional gait analysis is not available. Our purposes were to apply a translated EGS to standard video recordings of independent walking spastic diplegic CP patients, to evaluate its intraobserver and interobserver reliability with respect to gait analysis familiar and not familiar observers. Methods Ten standard video recordings acquired during routine clinical gait analysis were examined by eight observers gait analysis interpretation experienced or not, out of various specialities, two times with a two weeks interval. Kappa statistics and intraclass correlation coefficient were calculated. Results Better reliability was observed for foot and knee scores than in proximal segments with significant differences between stance and swing phase. Significantly better results in gait analysis trained observers underlines the importance to either be used to clinical gait analysis interpretation, or to benefit of video analysis training before observational scoring. Conclusion Visual evaluation may be used for outcome studies to explore clinical changes in CP patients over time and may be associated to other validated evaluation tools.

Summary Introduction Pectus excavatum (PE) is a congenital deformity essentially responsible for an unattractive aspect, much more rarely for compression problems. The classical treatments consist either in filling the excavation or in open thoracic reconstruction (the Ravitch technique). Alternatively, the treatment described by Nuss raises the sternum with a retrosternal metallic bar placed under thoracoscopic guidance. We present the preliminary results of a series of 25 children operated on using this technique. Hypothesis The minimally invasive procedure described by Nuss is a valid surgical strategy to treat PE. Materials and methods Twenty-five patients were operated on between February 2004 and April 2007 by the same surgeon. Nineteen of these patients presented a purely cosmetic indication. The six other patients were considered to have a more severe form of PE, with cardiorespiratory repercussions. In this group, there were two cases of Marfan syndrome and two patients presenting a history of previous cardiothoracic surgery. The technique has always consisted in placing a retrosternal bar through two lateral incisions. The surgery was always performed with right lung exclusion and was guided by thoracoscopy in 21 cases. In four particularly severe cases, a subxiphoid approach was required, making endoscopic guidance unnecessary. The severity of the lesion was evaluated by the Haller Index. All the patients had regular clinical follow-up (at three weeks, three months, and then every six months); assessment of pain, satisfaction with the cosmetic results, and perceived improvement in respiratory function were the criteria used for this follow-up. Results The cosmetic result was judged to be positive by 24 patients. One patient was dissatisfied (because of the asymmetrical shape resulting from the use of a single implant). Five patients presented minor complications with no repercussions on the cosmetic or functional result. One case of secondary bar displacement required revision on day 15. Following this revision evolution was uncomplicated (discharge on day 7 and activities resumed at three weeks). Finally, the hardware was removed at a delay after implantation ranging from one to two years. As of today, 13 patients have had their hardware removed with no complications or loss of the initial result. Discussion The original indication of the Nuss technique remains symmetrical PE in seven to 14-year-old children. The insubstantial scarring makes the technique valuable in the purely cosmetic forms of the condition. Based on this series, our technique has evolved toward certain adjustments depending on the severity and the etiology of the lesion. The most reported complication in the literature is secondary displacement of the bars. This problem is easily controlled by attaching the bar to a rib. Over the years, we have modified the implant design so as to improve its tolerance and stability. In asymmetrical forms of PE, implanting two bars has provided better efficacy. When a major form is present or when there is a history of cardiorespiratory problems, we recommend a short subxiphoid incision to release the pleural and pericardial adherences, precluding the need for thoracoscopic guidance. With these simple adjustments, this technique gains in reliability for cosmetic indications and its use can be extended to specific forms such as collagenosis or postoperative deformities. Level of evidence: Level IV. Therapeutic Study.

Corneal collagen crosslinking (CXL) is, at present, the only treatment that can slow or even stop the progression of keratoconus. It uses riboflavin and ultraviolet A (UVA) to create covalent bonds ("crosslinks") between collagen fibrils thus increasing corneal rigidity. Although to date there has been no direct evidence of intrastromal corneal crosslinking, several studies have reported the safety and efficacy of the conventional CXL protocol. This protocol is indicated for progressive keratoconus with a minimal corneal thickness (without the epithelium) of at least 400 μm. It should be performed as early as possible in patients under 18 years with keratoconus or with post-LASIK ectasia. Because of the epithelial debridement, it may rarely induce complications such as infectious keratitis or stromal scars. A variety of new protocols is under investigation and may reduce the rate of these complications. In addition, combination of CXL with other surgical treatments (intracorneal ring segments or photorefractive keratectomy) may improve visual outcomes in patients with keratoconus. Finally, the antimicrobial and anti-edematous properties of CXL have been shown, suggesting new therapeutic indications of this procedure such as infectious keratitis or stromal edema in the future.

Mucopolysaccharidoses (MPS) are a group of disorders characterized by the accumulation of glycosaminoglycans. Skeletal abnormalities are early and prominent features of MPS. Cervical spine and atlantoaxial instability, thoracolumbar kyphosis, hip dysplasia and osteonecrosis, genu valgum, and carpal tunnel syndrome are frequently observed. MPS disease-awareness is important for pediatric healthcare providers who should be able to recognize the clinical presentation, musculoskeletal abnormalities, and radiographic findings associated with this group of disorders.

Mild head trauma can be associated with concussion, defined as transient brain function impairment without radiological findings. Sports-related concussion is also reported in pediatrics (rugby, ice hockey, football, boxing, etc.). Misdiagnosis can lead to persistent neurocognitive signs with athletic and academic problems. Consensual tools are available, but they are not well-known by first-line doctors, coaches, and patients or parents. Concussed players should not be allowed to return to the field on the same day. Return to play should be gradual over 3weeks or more. School activities may need to be modified to favor cognitive rest. Prevention is based on risk information and knowledge transfer, rule changes, and protective helmets, whose effectiveness is not always proven.

Under the Agreement on the Application of Sanitary and Phytosanitary Measures that came into force in 1995, it was stipulated that all World Trade Organisation (WTO) members are required to ensure that their sanitary and phytosanitary measures are based on assessment of the risks to human, animal or plant life or health. In doing so, they must take into account risk assessment techniques developed by relevant international organisations. WHO and FAO are two such international organisations that are of very high standard and influence. Their executive body, the Codex Alimentarius Commission has developed the concept of Microbiological Risk Assessment (MRA) in a wider framework called Risk Analysis. The aim of Risk Analysis is to provide a global standard for the interpretation of the acceptability of risks associated to foods to which consumers might be exposed. Microbiological Risk Assessment is an essential element of Risk Analysis because it specifies risks related to pathogenic micro-organisms in the food chain on the basis of sound science, combining qualitative and quantitative data in the areas of epidemiology and pathogenicity of micro-organisms with food production and handling. The concept is still in its infancy but is gaining wide acceptance globally. This paper will describe an inventory of MRA developments in Europe carried out under auspicion of the European Commission. It also gives the results of a literature survey concerning scientific publications on the topic MRA in which the activities in Europe are compared to those elsewhere.

Pelvic tilt is usually measured on a full spine sagittal view. The sacral-femoral-pubic angle (SFP) has been previously described as a reproducible method to estimate pelvic tilt on a pelvis AP view. The aim of our study is to determine the reliability of the extrapolated pelvic tilt (ePT) using the SFP angle in the pediatric population. We selected 240 full spine X-rays in our pediatric imaging database. The cohort was equally distributed according gender and age. The following parameters were measured: SFP angle on the AP view, pelvic tilt (PT), pelvic incidence (PI) and sacral slope (SS) on the sagittal view. Concordance between the measured pelvic tilt (mPT) and the calculated (ePT) value of PT was tested by a correlation test. Intra- and inter-observer reliability was tested for each parameter using ANOVA. Our cohort included 240 children aged from 1 to 20 years (mean age 10.7 years). Mean SFP angle was 68.98° ± 6.8, mPT was 6.67° ± 8.56, ePT was 6.04° ± 6.79. The mean PI (45.04° ± 11.09) and SS (38.63° ± 8.12) were comparable to previously published pediatric data according to age groups. Intra- and inter-observer reliability showed acceptable correlation. Concordance between mPT and ePT was higher in older children (patients >10 years). Estimated value of pelvic tilt using the SFP angle showed acceptable correlation to the pelvic tilt measured on sagittal view of the pelvis in children over 10 years. However, correlation rates were lower than previous publication in adult population. This simple method could accurately estimate the pelvic orientation on a single frontal view of the pelvis, which may be of particular interest in understanding the relationship between pelvic orientation and hip pathology. IV.

Outcome evaluation is an objective procedure to determine the impact and success of a therapeutic program, focusing on the patient's well being in daily life. It is important not to confuse the different concepts found in the health status classification and quality of life evaluation. Both are suitable for outcome evaluation and may be used according to the principles of evidence-based medicine. Outcome evaluation of a therapeutic program may be compared to a search in the literature and the level of evidence. The goal is to achieve direct benefits for the patient and society. Strategies to improve daily practice may be developed. Scientific societies can create database for outcome evaluation and develop standardized protocols for longitudinal outcome follow-up, as well as proposing this type of study to health authorities. Based on these results, a global view of the patient can be taken into consideration to influence medical, socioeconomic and health management patient care.

International audience; Introduction: Fracture is one of the main complications following external fixator removal used in cases of progressive lower limb lengthening; rates as high as 50% are found in the literature. The aim of this study was to determine the factors influencing this complication. Materials and methods: One hundred and eleven cases of lower limb lengthening were performed in 58 patients (40 femurs and 71 tibias). The mean age at surgery was 10.1 years old. Lengthening was performed in all cases with an external fixator alone, associated in 39.6% of cases with intramedullary nailing. The patients were divided into three groups according to disease etiology (congenital, achondroplasia and other). The fractures were classified according to the Simpson classification. Results: Twenty fractures were recorded (18%). Sixteen fractures were found in patients with congenital disease, four with achondroplasia and none in the group of other etiologies. The fracture was more often in the femur (27.5%) than in the tibia (12.7%). Discussion: The rate of fracture is influenced by different factors depending on the etiology of disease. In congenital diseases, the fracture rate is higher when there is lengthening of more than 15% of the initial length and a delay between surgery and the beginning of lengthening of less than 7 days. In patients with achondroplasia, the influence of a relative percentage of lengthening is less important than in those with congenital disease. However, to avoid fractures, lengthening should not be started in children under the age of nine. Moreover, lengthening should begin at least 7 days after the fixator has been placed. Type of study: Retrospective. Level of evidence: Level IV. (C) 2012 Elsevier Masson SAS. All rights reserved.

Summary Traumatic bone defects (BD) are rare in children. There are no pediatric series in the literature on this topic. The aim of this first pediatric series was to determine the epidemiological characteristics and evaluate the results of different treatments in this entity. Material and methods This retrospective multicenter study evaluated diaphyseal bone defects in cases in which bone reconstruction was performed. BD was either initial and associated with trauma or secondary, resulting from infected non-union. Results The series included 27 patients (17 boys and 10 girls), mean age 11.4 years old (3–16) (20 traffic accidents). At the outset of all patients’ history was an open fracture (one stage 1, seven stage 2, 11 stage 3A and seven stage 3B, 1 NR). BD involved 13 tibias, 9 femurs, three humerus, one radius and one ulna. Bone defects were initial in 20 cases and secondary in seven cases. They were less than 2 cm in two cases, between 2 and 5 cm in 9 cases, between 5 and 10 cm in 10 cases and more than 10 cm in six cases. Treatment of BD was immediate in one case and delayed in 26 cases. Techniques used included: induced membrane in 10 cases, bone transport in seven cases, bone autograft in eight cases, vascularized fibular transfer in one case, no bone reconstruction in one case. Union was obtained in 27 patients. Union was obtained within a mean 12.3 months BD (3–62). Fifteen patients presented with sequellae. Discussion Traumatic bone defects have a better prognosis in children than in adults. The thicker, more active and richly vascularized periosteum in children is an important prognostic factor. Treatment of BD requires good initial bone stabilization. Reconstruction depends on the integrity of the periosteum. In case of an intact periosteum, bone reconstruction does not seem necessary in young children. If one part of the periosteum is intact, a simple autograft seems sufficient even with extensive bone defects. In the absence of the periosteum or especially in case of infection, the induced membrane technique seems preferable, with bone transport or a vascularized bone transfer. Level of evidence IV: retrospective study.

Summary Background Pedicle screw constructs for spinal instrumentation in patients with adolescent idiopathic scoliosis (AIS) are effective in providing coronal plane correction but can result in loss of kyphosis, which in turn can lead to loss of lordosis. Hybrid constructs have been found superior over pedicle screw constructs in terms of thoracic kyphosis restoration. In this study, our objective was to compare outcomes with monoaxial versus polyaxial screws in an AIS population treated with hybrid constructs. Hypothesis Monoaxial screws provide better correction in the coronal plane but result in loss of thoracic kyphosis, whereas thoracic kyphosis is preserved when polyaxial screws are used. Material and methods We retrospectively analysed data from 60 patients (mean age, 15 years) with Lenke 1, 2, or 3 AIS treated using a hybrid construct with self-retaining bilaminar hook claws cranially, pedicle screws between the last instrumented vertebra and T11 caudally, and sublaminar universal clamps between the two extremities of the construct. Monoaxial screws were used in the first 30 patients (MS group) and polyaxial screws in the next 30 patients (PS group). Student's t test was performed to compare the two groups in terms of thoracic Cobb angle correction and T4-T12 kyphosis 3 months after surgery. Results No significant preoperative differences were found between the two groups. At last follow-up, the residual Cobb angle was significantly greater in the PS group than in the MS group (20.3° versus 15°) with a percentage of correction of 72.1% in the MS group versus 64.8% in the PS group. In the sagittal plane, the thoracic kyphosis was significantly greater in the PS group than in the MS group (26.6° versus 23°). Discussion This preliminary study shows that, even within a population managed using hybrid constructs, which are associated with less iatrogenic hypokyphosis, differences exist according to the technique used. The importance of sagittal spinal balance has been abundantly documented in the literature, and sagittal malalignment, particularly due to iatrogenic factors, is associated with poorer clinical outcomes in adults with spinal deformities. Therefore, there is a critical need to determine whether the treatment priority is optimal correction in the coronal plane or in the sagittal plane. We believe that the main focus should be sagittal plane correction, even at the expense of a slight decrease in coronal plane correction. Long-term studies are needed to confirm our preliminary findings. Level of evidence IV, retrospective case-series study.

Twenty-two patients with metaphyseal primary malignant bone tumors (17 osteosarcomas, 5 Ewing's tumors) occurring before closure of the growth plate were examined with plain radiographs and MRI in order to determine the physeal or epiphyseal extent of the tumor. Results were correlated with the pathologic examination. Transphyseal spread was pathologically proven in 13 cases (59%): 12 cases of osteosarcoma and 1 case of Ewing's tumor (70% and 20%, respectively). There was no significant relation between epiphyseal invasion, age of patient, length of tumor or, in the cases of osteosarcoma, response to chemotherapy. Plain radiographs showed epiphyseal involvement in 4 cases and there were 10 false negatives. MRI revealed epiphyseal involvement in all cases; there were no false positives or false negatives. T1-weighted images in coronal or sagittal planes appeared to be sufficient. These findings are very useful in planning surgical limb salvage procedures and stress the ineffectiveness of the "barrier effect" of the growth plate against tumor spread.

Pediatric orthopedics is the basis of orthopedic surgery. ‘‘ortho’’ from the Greek word ‘‘orthos’’ meaning ‘‘to make straight’’ and ‘‘pedis’’ meaning ‘‘child’’ are the roots of the term ‘‘orthopedic’’, which has gradually evolved to include treatment of the entire osteo-articular system. Pediatric surgery presents particular growth-related problems [1]. Vertebral surgery of spine deformities is a major branch of pediatric surgery and it is vital to comply with strict procedures to avoid damaging effects on patients once they have become adults [2]. Non-surgical treatments are often poorly understood or not well taught, resulting in unsuitable forms of therapy. Bracing [3] has been seen to be effective. Three-dimensional analysis using a low-dose imaging system [4] such as EOS (EOS Imaging Paris, France) provides an accurate analysis of vertebral rotations as well as predictive information as to the possible evolution of scoliosis deformities [5]. Surgical treatment of deformities in children can correct or halt any unfavorable evolution of kyphoscoliotic curvature [6] and dysplastic spondylolisthesis [6]. The high potential risk of spontaneous fusion of vertebra after surgical decompression has led to performing surgical procedures at a distance from the vertebral axis by spineto-rib-cage distraction in strict compliance with operating procedures [7]. It is very important to know how to use screws, hooks, and other means of laminar fixation correctly to avoid any hypercorrection and post-surgical flatback syndrome, which causes long-term sagittal balance disorders. Early surgery during growth should take into account the risk of the crankshaft phenomenon described by Dubousset [8]. This supplement summarizes the current techniques used in pediatric spinal surgery based on the experience of teams recognized as experts in the field.

The rate of infection is extremely low after a prophylactic contralateral fixation in slipped upper femoral epiphysis, and exclusively involves superficial wound infection. We report an unusual case of hip infection after a prophylactic pinning with a single cannulated screw. The evolution was unfavorable, with necrosis and epiphysiolysis of the femoral head. A total hip arthroplasty was performed after 1 year of evolution.

Sixty-two patients with histiocytosis X were followed for an average of 5 years. The patients were classified into three groups: general visceral types (14 cases), multiple eosinophilic granulomas (nine cases), and solitary eosinophilic granulomas (39 cases). One hundred bony lesions were noted in 60 of the 62 patients. The bone lesions showed progressive improvement in single and multiple eosinophilic granulomas independent of treatment type. After biopsy, patients received no treatment unless there was a dangerous extension into the soft tissues because of its site, i.e., in the skull. In the general visceral types, chemotherapy was effective in visceral sites and in extensions of the tumor outside the bone but did not alter the natural history of the bony lesion.

The therapeutic objective of a congenital radial clubhand is to obtain, at the end of the growth, a functional hand, that is a hand with a thumb, in the axis of the forearm with the most cosmetic aspect as possible. The challenge lies in the fact that the hand is not in the axis of the forearm. Thus, some authors realize a surgical centralization or radialization by doing a direct release of the retracted soft tissues. On the other hand, it is possible to correct the hand without any invasive surgery by using an external fixator allowing to correct the hand progressively. The Taylor Spatial Frame fixator is a system of external fixation which allows, by using a software, to realize this correction accurately.

Treatment methods for ankle injury in children are numerous and have comparable results. The impact on absenteeism and quality of life is an interesting criterion to consider in order to help doctors in their initial treatment choice.The objective of this study was to compare two therapeutic strategies for ankle injury without fracture in children in terms of the impact on school absenteeism, parents' professional absenteeism, and quality of life. The strategies compared were cast immobilization of the ankle and a purely symptomatic treatment with no immobilization.We conducted a prospective, comparative, and randomized study. The population comprised children between 8 and 15 years of age, consulting for a first episode of ankle injury in a pediatric-emergency department of a hospital center in Marseille, France. A clinical and radiographical report was systematically done. Children were seen after 1 week to provide the clinical monitoring, assess the child's and parents' absenteeism, and assess the quality of life.Sixty-two patients were studied. There was no difference in clinical progression after 7 days between the two treatment groups. Quality of life was also comparable. However, the children's absenteeism and the parents' absenteeism were higher in the casted group.

We report on the case of a 2-year-old child with extra-articular osteoïd osteoma of the proximal femur leading to subluxation and coxa valga deformity of the hip joint at 10 year follow-up. The osteoïd osteoma reccured twice after surgical excision and percutaneous drilling. Patient's clinical history also reported a prolonged use of medications as treatment for these two recurrences. Second recurrence was combined with migration of the femoral head and retraction of the adductors: surgical treatment consisted in varus osteotomy to facilitate excision of the lesion, combined with a tenotomy of the hip adductors. Functional outcomes were satisfactory after 4-year follow-up. Reviews of the literature report two cases of hip subluxation secondary to intra-articular osteoïd osteoma. From our experience, it seems that hip subluxation in the present case could have been avoided with early surgical management.

Bezoars result from the aggregation of ingested materials (food, drugs, hair) that accumulate at a certain anatomic level in the gastrointestinal tract. It is a rare condition, which is favoured by a reduction in intestinal motility, or by a primary abnormality reducing the patency of gastrointestinal tract.We present a case when acute respiratory symptoms revealed an oesophageal bezoar. The patient presented with compression of the posterior tracheal wall by an oesophageal bezoar. The diagnosis was confirmed by oesophageal endoscopy. Treatment consisted in endoscopy-guided fragmentation and removal of the bezoar followed by topical lavage.Oesophageal bezoars may account for compression of the posterior tracheal wall causing acute respiratory failure or difficult weaning from the ventilator. The close anatomic proximity between the gastrointestinal and respiratory tract may explain the impact of oesophageal bezoars on the respiratory tract.

SummaryLimb deformities in children can be corrected using different techniques, notably external fixation following the Ilizarov principles. However, correction can be difficult in cases of multiple deformities. In 1994, Charles Taylor developed a new computer-assisted hexapodal external fixator system to treat these pathologies, the Taylor Spatial Frame™. The objective of this study was to evaluate the results obtained with this technique in treating lower-limb deformities in children.Thirty-six patients were included in this prospective study, with a mean age of 11.1 years. The etiologies were distributed into six groups: congenital pathologies in 17 cases, fractures in five cases, post-traumatic pathologies in two cases, postinfectious sequelae in three cases, achondroplasia in three cases, and other causes in the last six cases. A total of 67 deformities in the three spatial planes were found in the entire group of patients. The procedure consisted of lengthening, correcting the axis, or both simultaneously. All the patients were managed with the same protocol: placement of an external fixator, AP and lateral X-rays, and planning of the correction using dedicated software.In this group of 36 patients, the fixator was worn for a mean 183 days; when lengthening was performed, a mean 4.3cm was gained with a healing index of 38.2 days/cm. Of the 67 initial deformities, 91% were corrected. The most frequently encountered complications were a superficial infection in 22.2% of the cases; one deep infection was also noted as well as three bone regenerate fractures.Use of this computer-assisted fixation system seems effective in treating complex deformities of the limbs in children, and allows treating several deformities simultaneously.