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Background One of the treatment options for long head of the biceps tendon (LHBT) pathology is tenotomy. To our knowledge, no study in the literature has evaluated the degree of retraction after tenotomy. The goals of this study were to determine the distance of this retraction and to identify its relationship with patient characteristics. Methods We conducted an observational prospective survey over a 3-month period among 30 patients operated on arthroscopically by the same surgeon between August 2018 and April 2019. A radiopaque device was introduced inside the LHBT before tenotomy. Radiographs were obtained to evaluate the distance of retraction on day 1, day 30, and day 90. Results Thirty patients were included, of whom 63.3% (19) were women. Surgery was performed for a rotator cuff tear in 10 patients (33.3%) and for subacromial impingement in the remainder of patients (66.7%) after failure of conservative management. The mean retraction of the LHBT (distance between the glenoid and clip) increased from 1.9 cm (day 1) to 3.5 cm (day 90). Three radiographic measurements were performed, and all 3 showed significant increases from day 1 to day 90. According to the Student t test, the mean retraction in the subacromial impingement group was significantly higher than that in the rotator cuff tear group on day 1, day 30, and day 90. Body mass index, younger age, sex, and dominant hand did not show any relation with LHBT retraction (P > .05). The mean LHBT retraction was significantly higher on day 90 in patients presenting with a positive Popeye sign (P Conclusion At 3 months of follow-up, the mean LHBT retraction was 3.5 cm from the glenoid and 2.5 cm from the greater tuberosity. It dynamically increased from day 1 to day 90. The LHBT will retract and sit beyond the transverse humeral ligament in the bicipital groove. The LHBT retracts significantly more when early mobilization of the shoulder is allowed.

Adolescent idiopathic scoliosis (AIS) is the most common spinal disorder in children. A severity index was recently proposed to identify the stable from the progressive scoliosis at the first standardized biplanar radiographic exam. The aim of this work was to extend the validation of the severity index and to determine if curve location influences its predictive capabilities. AIS patients with Cobb angle between 10° and 25°, Risser 0–2, and no previous treatment were included. They underwent standing biplanar radiography and 3D reconstruction of the spine and pelvis, which allowed to calculate their severity index. Patients were grouped by curve location (thoracic, thoracolumbar, lumbar). Patients were followed up until skeletal maturity (Risser ≥ 3) or brace prescription. Their outcome was compared to the prediction made by the severity index. In total, 205 AIS patients were included; 82% of them (155/189, 95% confidence interval [74–90%]) were correctly classified by the index, while 16 patients were unclassified. Positive predictive ratio was 78% and negative predictive ratio was 86%. Specificity (78%) was not significantly affected by curve location, while patients with thoracic and lumbar curves showed higher sensitivity (≥ 89%) than those with thoracolumbar curves (74%). In this multicentric cohort of 205 patients, the severity index was used to predict the risk of progression from mild to moderate scoliosis, with similar results of typical major curve types. This index represents a novel tool to aid the clinician and the patient in the modulation of the follow-up and, for progressive patients, their decision for brace treatment. • The severity index of adolescent idiopathic scoliosis has the potential to detect patients with progressive scoliosis as early as the first exam. • Out of 205 patients, 82% were correctly classified as either stable or progressive by the severity index. • The location of the main curve had small effect on the predictive capability of the index.

Adults with spinal deformity (ASD) are known to have spinal malalignment affecting their quality of life and daily life activities. While walking kinematics were shown to be altered in ASD, other functional activities are yet to be evaluated such as sitting and standing, which are essential for patients’ autonomy and quality of life perception. In this cross-sectional study, 93 ASD subjects (50 ± 20 years; 71 F) age and sex matched to 31 controls (45 ± 15 years; 18 F) underwent biplanar radiographic imaging with subsequent calculation of standing radiographic spinopelvic parameters. All subjects filled HRQOL questionnaires such as SF36 and ODI. ASD were further divided into 34 ASD-sag (with PT > 25° and/or SVA >5 cm and/or PI-LL >10°), 32 ASD-hyperTK (with only TK >60°), and 27 ASD-front (with only frontal malalignment: Cobb >20°). All subjects underwent 3D motion analysis during the sit-to-stand and stand-to-sit movements. The range of motion (ROM) and mean values of pelvis, lower limbs, thorax, head, and spinal segments were calculated on the kinematic waveforms. Kinematics were compared between groups and correlations to radiographic and HRQOL scores were computed. During sit-to-stand and stand-to-sit movements, ASD-sag had decreased pelvic anteversion (12.2 vs 15.2°), hip flexion (53.0 vs 62.2°), sagittal mobility in knees (87.1 vs 93.9°), and lumbar mobility (L1L3-L3L5: −9.1 vs −6.8°, all p < 0.05) compared with controls. ASD-hyperTK showed increased dynamic lordosis (L1L3–L3L5: −9.1 vs −6.8°), segmental thoracic kyphosis (T2T10–T10L1: 32.0 vs 17.2°, C7T2–T2T10: 30.4 vs 17.7°), and thoracolumbar extension (T10L1–L1L3: −12.4 vs −5.5°, all p < 0.05) compared with controls. They also had increased mobility at the thoracolumbar and upper-thoracic spine. Both ASD-sag and ASD-hyperTK maintained a flexed trunk, an extended head along with an increased trunk and head sagittal ROM. Kinematic alterations were correlated to radiographic parameters and HRQOL scores. Even after controlling for demographic factors, dynamic trunk flexion was determined by TK and PI-LL mismatch (adj. R2 = 0.44). Lumbar sagittal ROM was determined by PI-LL mismatch (adj. R2 = 0.13). In conclusion, the type of spinal deformity in ASD seems to determine the strategy used for sitting and standing. Future studies should evaluate whether surgical correction of the deformity could restore sitting and standing kinematics and ultimately improve quality of life.

Background: Clinical and molecular data on the occurrence and frequency of inherited neuromuscular disorders (NMD) in the Lebanese population is scarce. Objective: This study aims to provide a retrospective overview of hereditary NMDs based on our clinical consultations in Lebanon. Methods: Clinical and molecular data of patients referred to a multi-disciplinary consultation for neuromuscular disorders over a 20-year period (1999–2019) was reviewed. Results: A total of 506 patients were diagnosed with 62 different disorders encompassing 10 classes of NMDs. 103 variants in 49 genes were identified. In this cohort, 81.4% of patients were diagnosed with motor neuron diseases and muscular dystrophies, with almost half of these described with spinal muscular atrophy (SMA) (40.3% of patients). We estimate a high SMA incidence of 1 in 7,500 births in Lebanon. Duchenne and Becker muscular dystrophy were the second most frequently diagnosed NMDs (17% of patients). These disorders were associated with the highest number of variants (39) identified in this study. A highly heterogeneous presentation of Limb Girdle Muscular Dystrophy and Charcot-Marie-Tooth disease was notably identified. The least common disorders (5.5% of patients) involved congenital, metabolic, and mitochondrial myopathies, congenital myasthenic syndromes, and myotonic dystrophies. A review of the literature for selected NMDs in Lebanon is provided. Conclusions: Our study indicates a high prevalence and underreporting of heterogeneous forms of NMDs in Lebanon- a major challenge with many novel NMD treatments in the pipeline. This report calls for a regional NMD patient registry.

International audience; Background: Adults with spinal deformity (ASD) are known to have postural malalignment affecting their quality of life. Classical evaluation and follow-up are usually based on full-body static radiographs and health related quality of life questionnaires. Despite being an essential daily life activity, formal gait assessment lacks in clinical practice.Research Question:What are the main alterations in gait kinematics of ASD and their radiological determinants?Methods:52 ASD and 63 control subjects underwent full-body 3D gait analysis with calculation of joint kinematics and full-body biplanar X-rays with calculation of 3D postural parameters. Kinematics and postural parameters were compared between groups. Determinants of gait alterations among postural radiographic parameters were explored.Results:ASD had increased sagittal vertical axis (SVA:34 ± 59 vs −5 ± 20 mm), pelvic tilt (PT:19 ± 13 vs 11 ± 6°) and frontal Cobb (25 ± 21 vs 4 ± 6°) compared to controls (all p

Purpose This study evaluates intraoperative disappearance of motor waveforms related to patient positioning in neurologically asymptomatic patients with spinal deformity. Methods This is a retrospective review of 190 neurologically asymptomatic patients aged seven to 17 years planned for posterior instrumentation under neuromonitoring. There were 159 patients with adolescent idiopathic scoliosis and 31 patients with secondary scoliosis. Patients underwent surgery with transcranial electric stimulation motor evoked potentials (TES-MEPs). In case of abnormal findings, surgery was temporarily discontinued and necessary measures undertaken. In case of permanent signal disappearance surgery was definitively discontinued. Results Six patients showed permanent loss of signal during early stages of surgery. These patients had a mean major curve of 64° Cobb angle and a mean thoracic kyphosis (D2 to D12) of 72°. The 184 remaining patients had a mean major curve of 50° Cobb angle and a thoracic kyphosis of 35°. A retrospective descriptive review of the patients’ radiographs shows hyperkyphosis to be the common ground between the six secondary scoliosis cases. Gradual preoperative traction maintained during the surgery applied in two of these patients taken back to surgery six months later was associated with maintenance of TES-MEP signals throughout the surgery. Conclusion This study shows that positional permanent loss of neuromonitoring signals is more likely to occur in patients with secondary scoliosis and hyperkyphosis shown to have sharper spine deformity and suspected to have a more vulnerable spinal cord. Gradual skeletal traction performed in two of these patients and maintained during surgery showed promising results. Level of Evidence IV

Background A thorough review of the available orthopaedic literature shows significant controversies, inconsistencies and sparse data regarding the terminology used to describe foot deformities. This lack of consensus on terminology creates confusion in professional discussions of foot anatomy, pathoanatomy and treatment of deformities. The controversies apply to joint movements as well as static relationships between the bones. Description The calcaneopedal unit (CPU) is a specific anatomical and physiological entity, represented by the entire foot excepted the talus. The calcaneus, midfoot and forefoot are solidly bound by three strong ligaments that create a unit that articulates with the talus. The movement of the CPU is complex, as it rotates under the talus, around the axis of Henke that coincides with the talo-calcaneal ligament of Farabeuf. This calcaneopedal unit is deformable. It is compared with a twisted plate, able to adapt to many physiological situations in standing position, in order to acheive a plantigrade position. Moreover, the calcaneopedal unit and the talo-tibiofibular complex are interdependent; rotation of the latter produces morphologic modifications inside the former and vice versa. Purpose This paper is a review article of this concept and of its physiopathological applications.

International audience; Purpose: To explore 3D hip orientation in standing position in subjects with adult spinal deformity (ASD) presenting with different levels of compensatory mechanisms.Methods: Subjects with ASD (n = 159) and controls (n = 68) underwent full-body biplanar X-rays with the calculation of 3D spinopelvic, postural and hip parameters. ASD subjects were grouped as ASD with knee flexion (ASD-KF) if they compensated by flexing their knees (knee flexion ≥ 5°), and ASD with knee extension (ASD-KE) otherwise (knee flexion

Clubfoot is the most frequent congenital deformity involving the foot. Little is known about the management of this disease in the Middle East as sparse data is available in the literature. Through the last 5 decades, congenital clubfoot management in the Middle East went from manipulation through Kite's technique in the late seventies, to early primary surgical intervention in the late eighties and early nineties of the previous century, and then back to manipulation with Ponseti's technique and the French functional technique in the late nineties, with the latter falling out of favor with time. This is comparable to the evolution of management witnessed in the United States and in Europe, with 10 to 15 years of delay. The delay is getting shorter with time due to the easier access to published scientific data and the increasing number of fellows from Middle East travelling to referral centers in Europe and the USA. A survey was performed among pediatric orthopedic surgeons in the Middle East to assess their approach to clubfoot management. This is the first survey of its kind in the region. It showed a wide adoption (97.1%) of the Ponseti's technique with serial manipulation and casting, Achilles tenotomy followed by abduction bracing. Divergent practices were found concerning the upper age limit for Ponseti treatment and the setting of the Achilles tenotomy. Nevertheless, these subjects are still a matter of debate in the literature and international conferences. All in all, pediatric orthopedic surgeons in the Middle East are offering their patients the gold standard of care. However, lot of work is to be done in raising awareness for this disease in the community, and among our colleagues as prenatal screening for clubfoot in the Middle East is practically nonexistent.

Talar injuries represent serious medico-surgical conditions because of the involvement of the talus in multiple articulations, such as the subtalar, the transverse talar, and the ankle joint complex. Its complete detachment from the surrounding ligaments and bone is known as talar extrusion, a very rare injury with a complicated treatment course. We report a case of a 43-year-old female patient presenting with a non-retrieved complete left talar body extrusion associated with a floating knee, manifested by left tibial shaft fracture and left supracondylar femoral fracture. The patient was treated with open reduction and internal fixation for the floating knee and a manually shaped talar cement spacer with staged tibiocalcaneal arthrodesis for the ankle. The patient was monitored over a six-year period. This case is reported for the extreme rarity of lost open talar body extrusion, and its problematic treatment in the absence of clear guidelines, especially with the presence of multiple concomitant ipsilateral fractures of the limb, such as floating knee, as in this case.

Introduction: Maintaining balance during gait allows subjects to minimize energy expenditure and avoid falls. Gait balance can be measured by assessing the relationship between the center of mass (COM) and center of pressure (COP) during gait. Demographics, skeletal and postural parameters are known to influence gait balance. Purpose: What are the determinants of dynamic balance during gait in asymptomatic adults among skeletal and demographic parameters? Methods: 115 adults underwent 3D gait analysis and full-body biplanar X-rays. Angles between the COM-COP line and the vertical were calculated in frontal and sagittal planes during gait: maxima, minima, and ROM were evaluated. Full-body 3D reconstructions were obtained; skeletal and postural parameters of the spine (lumbar lordosis, thoracic kyphosis, sagittal vertical axis SVA), pelvis (pelvic tilt and incidence, acetabular orientation in the 3 planes) and lower limbs (neck shaft angle femoral and tibial torsions) were calculated. A univariate followed by a multivariate analysis were computed between the COM-COP parameters and skeletal and demographic parameters. Results: The univariate analysis showed that in the frontal plane, maximum (4.6°) of the COMCOP angle was significantly correlated with weight (r =0.53), age (r =0.28), height (r = 0.35), SVA (r = 0.23), T1T12 (r = 0.24) and pelvic width (r = 0.25).In the sagittal plane, maximum COM-COP (19.7 ± 2.8°) angle was significantly correlated to acetabular tilt (r = 0.25) and acetabular anteversion (r =0.21). The multivariate analysis showed that, in the frontal plane, an increase in the maximum of the COM-COP angle was determined by a decreasing height (β = −0.28), an increasing weight (β = 0.48), being a male (β = −0.42), and an increasing posterior acetabular coverage (β = 0.22). In the sagittal plane, an increasing maximum COMCOP angle was determined by a decreasing height (β = −0.38) and an increasing SVA (β = 0.19). Conclusion: Frontal imbalance appeared to be mainly correlated to demographic parameters. Sagittal imbalance was found to be correlated with weight, height, acetabular parameters and SVA. These results suggest that in addition to demographic parameters, acetabular parameters and SVA are important determinants of balance during gait. This research was funded by the University of Saint-Joseph (grant FM183). The funding source did not intervene in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

Idiopathic scoliosis is a disease of the growing spine. Risk of progression and aggravation of disease are mainly dictated by the remaining growth and curve magnitude. Remaining growth can be estimated by repeated biometric measurements, tanner sign and bone age estimation. Puberty is the turning point in the natural history of this disease. The first two years following puberty are the turning point in the natural history of this disease since 90% of growth occurs during this period. Lateral olecranon radiograph is effective for estimating bone age during this phase. Growth acceleration is followed by a deceleration phase of three years where menarche occurs. Bone age during this phase is evaluated by hand X-rays and the Risser sign. Progression risk assessment of idiopathic scoliosis showed that a 30° curve at the beginning of puberty together with 20° to 30° curves with more than 10° of annual curve progression has a 100% risk of progression towards the 45° surgical threshold. In these patients, anticipation may be the key for effective treatment strategy. Treating these curves earlier than the surgical threshold before increased stiffness would lead to a better outcome.

International audience; Introduction: Postural alignment is altered with spine deformities that might occur with age. Alteration of spino-pelvic and postural alignment parameters are known to affect daily life activities such as gait. It is still unknown how spino-pelvic and postural alignment parameters are related to gait kinematics. Research question: To assess the relationships between spino-pelvic/postural alignment parameters and gait kinematics in asymptomatic adults. Methods: 134 asymptomatic subjects (aged 18-59 years) underwent 3D gait analysis, from which kinematics of the pelvis and lower limbs were extracted in the 3 planes. Subjects then underwent full-body biplanar X-rays, from which skeletal 3D reconstructions and spino-pelvic and postural alignment parameters were obtained such as sagittal vertical axis (SVA), center of auditory meatus to hip axis plumbline (CAM-HA), thoracic kyphosis (TK) and radiologic pelvic tilt (rPT). In order to assess the influence of spino-pelvic and postural alignment parameters on gait kinematics a univariate followed by a multivariate analysis were performed. Results: SVA was related to knee flexion during loading response (β = 0.268); CAM-HA to ROM pelvic obliquity (β = -0.19); rPT to mean pelvic tilt (β = -0.185) and ROM pelvic obliquity (β = -0.297); TK to ROM hip flexion/extension in stance (β = -0.17), mean foot progression in stance (β = -0.329), walking speed (β = -0.19), foot off (β = 0.223) and step length (β = -0.181). Significance: This study showed that increasing SVA, CAM-HA, TK and rPT, which is known to occur in adults with spinal deformities, could alter gait kinematics. Increases in these parameters, even in asymptomatic subjects, were related to a retroverted pelvis during gait, a reduced pelvic obliquity and hip flexion/extension mobility, an increased knee flexion during loading response as well as an increase in external foot progression angle. This was associated with a decrease in the walking pace: reduced speed, step length and longer stance phase.

Normative values of sagittal alignment are used as references for the diagnosis and treatment of spinal pathologies. There are currently no reference values for the normative sagittal alignment of Lebanese subjects. The objective is to describe normative values of full body sagittal alignment parameters in asymptomatic Lebanese adults and to compare the sagittal alignment of this population to that of populations of various origins.Included subjects were aged 18 to 28 years old. Each subject underwent a full body biplanar X-ray exam with measurement of spine, pelvis and lower limb parameters of sagittal alignment. The sagittal alignment of the Lebanese population was compared to that of other ethnicities, previously reported in the literature, using one-way ANOVA.Ninety-two asymptomatic Lebanese young adult volunteers (48 males, 44 females, age=21.5±2.2 years) were enrolled in this study. The mean curvature in the cervical spine was kyphotic (-4.3°) in women, while it was lordotic in men (5.4°). Men were found to be significantly more kyphotic than women (-58.3° vs. -53.0°; p0.01) but both sexes were found to have similar lordosis (61.6°) and pelvic incidence (52.0°). Lebanese subjects had intermediate pelvic incidence compared to other ethnicities but showed significantly higher thoracic kyphosis (p0.01) and lumbar lordosis (p0.01) compared to all other ethnicities.This study established reference normative values for young adult Lebanese subjects. Most women were found to have kyphotic cervical spines. The sagittal alignment of Lebanese subjects differed significantly compared to that of other ethnicities.Level IV - cross sectional study.

Background Cervical spinal alignment is usually assessed on full-body radiographs allowing for the concomitant evaluation of possible compensatory mechanisms that may occur at any level in the setting of postural malalignment. Hypothesis Cervical parameters measured on full-body radiographs are reliable. Patients and methods A total of 70 subjects were included and divided in 3 groups: asymptomatic adults (n = 21), adolescents with idiopathic scoliosis (n = 20), and adults with spinal deformity (n = 29), for whom full-body low-dose biplanar radiographs were obtained. Eighteen cervical parameters including gaze and cervical curvature, upper cervical spine, global cervical alignment, thoraco-cervical and cervico-pelvic parameters were measured by 4 operators, three times each. The intraclass correlation coefficient (ICC) and the 95% confidence interval (95% CI) where calculated for each parameter and compared between the 3 groups. Results ICC and the 95% CI were similar between the 3 groups. The measured parameters showed a very high repeatability (ICC > 0.8) except for C0-C2, which presented an average repeatability (ICC = 0.57). The cSVA, CTPA, C2-SPi, cranial offset, T1-SPi, CBVA and cranial tilt had a 95% CI 6°. Discussion The poor visibility of the foramen magnum, hard palate, C7, T1, and the sternum on radiographs could explain why certain parameters showed a higher measurement error. The assessment of these error margins is essential for an accurate evaluation of cervical spinal deformities and a proper therapeutic approach. Level of evidence III; retrospective analysis of prospectively collected data.

Purpose This study aims to review the results of sclerotherapy using Surgiflo in addition to alcohol in primary aneurysmal bone cysts (ABC). Methods A total of 16 consecutive patients with histologically confirmed diagnosis of primary ABC were treated by percutaneous Surgiflo and alcohol injection at our institution. Clinical follow-up included the assessment of pain, swelling, limping and functional impairment. Radiological parameters included tumour volume, physis-cyst distance, thickness of cyst cortex, and presence of intracystic septations. Mean follow-up was 35,6 months (24–71 months). Treatment was considered successful when the cyst volume decreased by a minimum of 10%, the bone cortex became thicker, and the distance to physis increased. Results Mean age at presentation was 9.5 years (5.16–13.84 years). All ABC's were primary and all patients underwent a single Surgiflo and alcohol session except for two (12.5%) who required a second session. All patients had a good clinical result at final follow-up. Satisfactory cyst healing was achieved in 11 cases according to radiological parameters. Tumour volume decreased from a mean of 122 cm3 (111 to 133) before injection to 86 cm3 (76 to 96) at last follow-up (p < 0.01). Physis-cyst distance increased from a mean of 1 cm (0.1 to 2) to 2.1 cm (0.5 to 4) at last follow-up (p < 0.01). Cortical thickness improved from 1 mm (0.5 to 1.5) to 2 mm (1 to 3.5) at last follow-up (p < 0.01). There were no treatment related complications. Surgery was performed in one patient having a C3 vertebra ABC after developing quadriparesis due to tumour progression. Conclusion Sclerotherapy using Surgiflo and alcohol may be used as an efficient, safe and minimally invasive alternative for the treatment of primary ABCs.

Residual acetabular dysplasia is a frequent cause of secondary osteoarthritis of the hip and its management is still controversial. The aim of this review is to describe residual acetabular dysplasia, to estimate the age limit above which surgical management is needed, and to emphasize the role of assistive imaging in evaluating predictive parameters for future acetabular development. A decision-making algorithm is presented.

Background Medial hamstring fractional lengthening is commonly performed in children with cerebral palsy (CP) to decrease contracture and/or to improve gait. Percutaneous procedures are gaining more and more popularity, even in the paediatric population, with equivocal results. The purpose of this paper was to determine the efficacy and safety of percutaneous medial hamstring myofascial lengthening (PHL). Methods This is a prospective randomised controlled trial including 31 knees from 18 consecutive patients with CP scheduled for medial hamstring lengthening in the setting of multilevel tendon lengthening procedures in a university hospital. Other concomitant lower extremity surgeries were not exclusionary. A first paediatric orthopaedic surgeon executes the PHL at one level, as recently described in the literature. Another surgeon opens and extends the wound to explore what had been cut during the PHL and completes fractional lengthening (OHL) of both the semimembranosus (SM) and semitendinosus (ST) when possible. Popliteal angle (PA) was assessed by a third surgeon immediately before PHL, after PHL and then after OHL, using a goniometer in a standardised reproducible manner. All three surgeons were blinded to the others’ findings. Primary endpoints included ease of performing PHL, the percentage of tendon-fascia/ muscle portion sectioned percutaneously and improvement of PA. Comparison between improvement of PA after PHL and OHL was done using a paired t-test with a 95% confidence interval. Results The first surgeon was at ease in palpating and identifying the semimembranosus tendon before PHL in ten knees only. PHL led to an undesirable cut of the semimembranosus muscle fibres to more than 50% of the muscle section area in eight cases (Conclusions To the authors’ knowledge, this is the first prospective study concerning the anatomic effects of PHL. Although it is a quick procedure, it is often associated with difficulty by the operating surgeon to identify and evaluate what should be cut percutaneously, leading to abusive injury of the muscle itself rather than the fascia alone. In addition, the gain in PA is statistically less following PHL than following OHL despite undesirable extensive muscle injury following PHL. This may be due to the multiple fascial cuts (fractional lengthening) usually performed in OHL.

Introduction Subjects with Down syndrome (DS) are known to be affected by various foot deformities. Despite the fact that some of these deformities have been reported in the literature, a more comprehensive description would be of benefit. The aim of this study is to investigate the prevalence of known foot deformities in patients with DS and of other previously non-described foot anomalies in this population. Hypothesis Subjects with DS have an increased prevalence of foot deformities compared to control subjects. Methods Fifty-five subjects with DS (age: 14.6 ± 7.4 years) had undergone podiatric clinical and podoscopic examinations to study their main foot deformities and their footprints, respectively. The results of these examinations were compared to those of an age-matched asymptomatic control group of fifty-three subjects (age: 13.4 ± 11.2 years). Results Significantly more prevalent foot deformities were found in the DS group: hallux valgus (36.4%), syndactyly between the 2nd and 3rd toes (9.1%), grade II pes planus (39.1%) and grade III pes planus (30%). Moreover, joint laxity (43.6%) was significantly more prevalent in the DS group. Furthermore, the presence of an increased space between the 1st and 2nd toes in patients with DS and its prevalence (73.6%) were described for the first time. A multivariate analysis revealed a significant relationship between the presence of joint laxity and flatfoot in only the control but not the DS group. Other foot deformities were found to be consistently more frequent in the DS population but not significantly higher than the control group. Discussion Although subjects with DS had significantly greater joint laxity and BMI compared to the control group, neither of these factors was found to be related to the increased prevalence of flatfoot in DS patients. Level of evidence IV–retrospective study.

Background During past decades, gradual bone transplant using external fixators and vascularized fibular or rib transplants widely contributed to solve difficult problems related to the reconstruction of large bone defects in children. However, these surgeries are time consuming and require specialized surgical skills, not always available in a general hospital setting, mainly in rural areas. Purpose To report the preliminary results of the more recently described induced membrane technique in a consecutive series of 8 children and to identify some factors related to the procedure's success. Methods Nine consecutive children with bone defects ranging from 5 to 14 cm were included in the study. The age at surgery ranged from 3 to 16 years. There were 3 congenital pseudarthrosis (CP) of the fibula, 1 CP of the tibia, 1 Ewing sarcoma of the tibia, 1 Ewing sarcoma of the ulna, 1 tibial osteosarcoma, 1 fibular osteosarcoma, and 1 chronic diffuse tibial osteomyelitis. The procedure was performed according to the original Masquelet's description in 2 stages. Follow-up ranged from 1 to 7 years. Results The child with tibial osteosarcoma died 3 months after the surgery from complications related to chemotherapy. Among the 8 remaining children, 6 healed uneventfully, and 2 required revision with additional grafting and/or better internal fixation, one with Ewing sarcoma of the tibia and a 13-cm bone defect and the second with CP of the fibula. Both of them had suboptimal internal stabilization. Conclusions The induced membrane technique is a useful, efficient, and simple alternative to highly specialized surgical procedures used for the reconstruction of large bone defects in children. Risk factors for failure include chemotherapy, suboptimal bone fixation, and persistent axial malalignment. Level of evidence Level IV.

Patients with adult spinal deformities (ASD) are known to have altered postural alignment affecting their quality of life and activities of daily living, especially gait. The Sagittal Vertical Axis (SVA), a postural parameter calculated as the distance between the posterior corner of the sacrum and the C7-plumbline on full-body sagittal radiographs [1], has been shown to be highly altered in ASD. Even though this parameter is positional and could vary during gait, no studies have investigated its variation during walking even in asymptomatic subjects.

Lower limb (LL) muscle morphology and growth are altered in children with cerebral palsy (CP). Muscle alterations differ with age and with severity of motor impairment, classified according to the gross motor classification system (GMFCS). Muscle alterations differ also with orthopedic intervention, frequently performed at the level of the shank muscles since an early age, such as the gastrocnemius. The aim was to investigate the alterations of treatment-naïve pelvis and thigh muscle lengths and volumes in children with GMFCS levels I and II, of varying ages. 17 children with CP (GMFCS I: N = 9, II: N = 8, age: 11.7 ± 4 years), age-matched to 17 typically developing (TD) children, underwent MRI of the LL. Three-dimensional reconstructions of the muscles were performed bilaterally. Muscle volumes and lengths were calculated in 3D and compared between groups. Linear regression between muscle volumes and age were computed. Adductor-brevis and gracilis lengths, as well as rectus-femoris volume, were decreased in GMFCS I compared to TD (p

The effect of dominance on upper limb (UL) kinematics has only been studied on scapular movements. Moreover, when an anatomical UL movement is performed in a specific plane, secondary movements in the remaining planes involuntarily occur. These secondary movements have not been previously evaluated. The aim of this study was to compare the kinematics of primary and secondary angles of dominant and non-dominant UL during anatomical movements in asymptomatic adults. 25 asymptomatic adults performed 6 anatomical movements bilaterally: shoulder flexion-extension, abduction-adduction, horizontal abduction-adduction, internal-external rotation, elbow flexion-extension and wrist pronation-supination. Kinematics of the dominant and non-dominant UL were compared by their ranges of motion (ROM) and their angular waveforms (Coefficient of Multiple Correlations, CMC). The comparison between dominant and non-dominant UL kinematics showed different strategies of movement, most notably during elbow flexion-extension (CMC = 0.29): the dominant UL exhibited more pronation at maximal elbow flexion. Significant secondary angles were found on most of the UL anatomical movements; e.g. a secondary ROM of shoulder (humero-thoracic) external-internal rotation (69° ± 16°) was found when the subject intended to perform maximal shoulder abduction-adduction (119° ± 21°). Bias of dominance should be considered when comparing pathological limb to the controlateral one. Normative values of primary and secondary angles during anatomical movements could be used as a reference for future studies on UL of subjects with neurological or orthopedic pathologies. This study was sponsored by the research council of the University of Saint-Joseph under the Grant number IPHY5

Cerebral palsy patients who undergo posterior spinal instrumentation for scoliosis are at a greater risk of surgical site infection compared to adolescents with idiopathic scoliosis. Many infecting organisms are reported. Risk factors include patients' specific factors, nutritional status as well as surgery related factors. Although surgical management is still controversial, it is always based on irrigation and debridement followed or not by implant removal. The purpose of this paper is to review the pathophysiology of surgical site infection in this patient population and to propose a treatment algorithm, based on a thorough review of the current literature and personal experience.

Radiographs are often performed to assess pelvic and hip parameters, but results depend upon correct pelvis positioning. Three-dimensional (3D) reconstruction from biplanar-radiographs should provide parameters that are less sensitive to pelvic orientation, but this remained to be evaluated.Computerized-tomographic scans of six patients were used both as a reference and for generating simulated frontal and lateral radiographs. These simulated radiographs were generated while introducing axial rotations of the pelvis ranging from 0° to 20°. Simulated biplanar-radiographs were utilized by four operators, three times each, to perform pelvic 3D-reconstructions. These reconstructions were used to assess the trueness, precision and global uncertainty of radiological pelvic and hip parameters for each position.In the neutral position, global uncertainty ranged between ± 2° for pelvic tilt and ± 9° for acetabular posterior sector angle and was mainly related to precision errors (ranging from 1.5° to 7°). With increasing axial rotation, global uncertainty increased and ranged between ± 5° for pelvic tilt and ± 11° for pelvic incidence, sacral slope and acetabular anterior sector angle, mainly due to precision errors.Radiological parameters obtained from 3D-reconstructions, based on biplanar-radiographs, are less sensitive to axial rotation compared to plain radiographs. However, the axial rotation should nonetheless not exceed 10°.• Pelvic radiological parameters could be affected by patient malpositioning. • Biplanar radiograph-based 3D reconstructions were performed at increments of axial rotation. • Trueness, precision and global uncertainty were evaluated for pelvic and hip radiological parameters. • Hip parameters were less affected by rotation compared to pelvic parameters. • Maintaining the pelvis close to the neutral position is recommended to ensure the highest possible accuracy.

BACKGROUND CONTEXT Adults with spinal deformity (ASD) are known to have postural malalignment affecting their quality of life. Classical evaluation and follow-up are usually based on full-body static radiographs and health related quality of life questionnaires. Despite being an essential daily life activity, a formal gait assessment is lacking in clinical practice. Moreover, gait alterations and their relationships with static deformities in ASD still remain to be elucidated PURPOSE To investigate gait alterations in subjects with ASD and their static radiographic determinants. STUDY DESIGN/SETTING Prospective Single Center. PATIENT SAMPLE A total of 52 Adult Spinal Deformity patients, and 63 control subjects. OUTCOME MEASURES Full body image, 3D gait analysis. METHODS A total of 52 Adult Spinal Deformity (ASD) patients age and weight-matched to 63 controls underwent full-body 3D gait analysis with extraction of 3D lower limb and trunk kinematics. All subjects underwent full-body biplanar X-rays with subsequent calculation of classical 3D postural parameters. Kinematics and postural parameters were compared between ASD and controls. Determinants of gait alterations among postural radiographic parameters were explored in ASD. RESULTS ASD subjects had significantly increased SVA (33.6±59 vs -4.6±20mm), CAM-HA (12±62 vs -21±26mm), PT (19±13 vs 11±6°), frontal Cobb (25±21 vs 4±6°) compared to controls (all p CONCLUSIONS Subjects with ASD are known to have spinal malalignment causing postural alterations such as forward bending of the trunk; they also recruit compensatory mechanisms in the pelvis and lower limbs by increasing radiographic pelvic tilt and knee flexion. This study showed that static compensations in the lower limbs persist during gait where ASD patient exhibit a flexed attitude at the trunk, hips and knees, a reduced hip mobility and loss of lordosis. ASD walked at a slower pace with an elevation of their single support time that might contribute to their stability while walking. These dynamic discrepancies were shown to be strongly related to skeletal radiological alterations, specifically the increased forward shift of the head and trunk, the pelvic retroversion and the lack of lumbar lordosis. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Provide primary care physicians with the best available evidence to support answers to frequently asked questions by caregivers of patients with adolescent idiopathic scoliosis (AIS).A review of best available evidence shows that schoolbag design and weight are not associated with higher odds of developing AIS. However, patients with AIS are more prone to balance problems with asymmetric backpack carrying and with rising weights. In patients with AIS, the backpack should be worn in a symmetric way and should never exceed 10% of the child's body weight. Although no relationship was found between systematic exercising in general and development of AIS, classical ballet and professional swimming in skeletally immature adolescents were associated to higher odds of having AIS. Since AIS affects adolescent girls mainly, women health issues are of paramount importance in this disease. Except for limited sexual activity and higher need for infertility treatment, patients with AIS perform similar to controls in marriage rates, age at first pregnancy, gestational age, offspring, labor and delivery. Best available evidence shows that adults with AIS diagnosed during adolescence have similar physical activity level compared with controls. In patients with AIS, adults with surgically treated idiopathic scoliosis have slightly lower physical activity level than previously braced and untreated patients.Although schoolbag weight isn't associated with higher odds of developing AIS, classical ballet and professional swimming in adolescents are. Except for limited sexual activity, patients with AIS perform similar to controls in remaining women health issues. Adults with AIS diagnosed during adolescence have similar physical activity level compared with controls.

Introduction The vertical position of the thoracic pad is a subject of controversy in brace design. Traditional recommendations dictate a maximal force applied at the level of the apical rib, about 2 levels below the apical vertebra. We sought to evaluate the optimal vertical position of the brace thoracic pad using fulcrum bending radiographs. Hypothesis A lateral force applied at the apical vertebra of a thoracic curve is more efficient at correcting coronal deformity than a force placed the apical rib. Patients and methods In this prospective study, we recruited patients presenting with adolescent idiopathic scoliosis (AIS) and Risser stage 0-2 over a period of 12 months. Patients with a history of spine or thoracic surgery were excluded. Two fulcrum bending radiographs were performed for each patient: one with the center of the fulcrum placed under the most lateral part of the apical rib and another with the fulcrum centered below the apical vertebra. Cobb angles were measured on each fulcrum radiograph and compared using a paired t test. Results Fifty-two patients were included, with a mean age of 12.4 years and mean thoracic Cobb angle of 39.4˚. Placing a fulcrum under the apical vertebra reduced the Cobb angle to a mean of 11.5˚, which was significantly lower than a fulcrum placed under the apical rib (14.3˚, p = 0.001). This corresponded to a 20% relative loss in the absolute correction angle when placing the fulcrum under the apical rib. The difference between the 2 Cobb angles was not significantly correlated to patient age (p = 0.896) or curve apex (p = 0.813). Discussion This is the first clinical study addressing the vertical position of the thoracic pad in braces for AIS. A lateral force applied at the level of the apical vertebra was significantly more efficient at reducing thoracic curve deformities than one applied at the apical rib. Our results provide clinical support to finite element studies that refute traditional recommendations of brace design, advocating for a revision of these guidelines to optimize non-operative treatment of AIS. Level of evidence II, prospective comparative study.

International audience; Postural parameters, calculated in static position on frontal andsagittal radiographs, are altered in ambulant children with cerebralpalsy (CP) and are known to be related to gait abnormalities [1,2]. Mostof these parameters are positional and could vary during gait. Theircomputation could be performed using gait simulation models that areusually generic or semi-personalized [2,3]. There are currently nostudies investigating how subject-specific postural parameters aremodified during gait in children with CP.

OBJECTIVE To present a series of pediatric cervical spine (CS) aneurysmal bone cysts (ABC), to review the literature, and to propose a treatment algorithm. MATERIAL We present a series of 4 cases of ABC and review the literature using PubMed, EMBASE, and Google scholar. RESULTS Only 51 cases are documented. The mean age at diagnosis is 11.5 years, and there is a small female predominance (F:M ratio=1.6). Most of ABC occurs in the upper CS (41%), are located in the posterior component (75%), and extends in 40% of the vertebral body. A single treatment modality was used in 56.9%, whereas combination of surgery with other treatment modalities was used in the rest. Of the total number of cases, 56.8% were managed with marginal resection, and instrumentation was used in 80%. Mean follow-up was 72.5 months, with the majority of patients disease free. Pain is the most common symptom present at the latest follow-up. CONCLUSIONS ABC of the spine is a pediatric tumor occurring rarely in the CS. Treatment options vary from simple curettage to total resection with or without instrumentation. Recurrence after surgery is highest after curettage alone. The main indications for surgery are rapid progression, despite intracystic injection, and/or the presence of neurological signs or symptoms.

Purpose There is currently an increasing trend for percutaneous surgical interventions mainly in children with cerebral palsy (CP). The purpose of this study was to evaluate the effectiveness and safety of percutaneous proximal gracilis tenotomy (PPGT) in children with CP scheduled for hip adductor tenotomy. Methods This is a prospective study of 59 hips in 31 consecutive patients with CP scheduled for hip adductor tenotomy in the setting of multilevel tenotomies or hip osteotomy (femoral or Dega). A pediatric orthopedic surgeon conducted a percutaneous adductor longus and gracilis tenotomy through the same stab wound. Another surgeon extended the wound to explore what had been cut during the PPGT, and completed the tenotomy if necessary (open proximal gracilis tenotomy; OPGT). Hip abduction with the hip and knee extended (HA) was assessed by a third surgeon (1) immediately before PPGT, i.e., directly after percutaneous adductor longus tenotomy (prePPGT), (2) after PPGT (postPPGT), and (3) following OPGT (postOPGT), using a goniometer, in a standardized reproducible manner. All three surgeons were blinded to each other's findings. Primary end-points included the percentage of muscle portion sectioned percutaneously and the improvement of HA angle. Comparison between HA before and after PPGT was performed using a paired t test with 95 % confidence interval (CI), and comparison between HA after PPGT and OPGT was performed using a Student's t-test with 95 % CI. The bleeding was assessed and other iatrogenic lesions were identified. The relationship between HA after PPGT and the percentage of muscle portion sectioned percutaneously was evaluated by calculating the Pearson correlation coefficient ( p < 0.01). Results Mean HA measured 33.71 degrees prePPGT and increased to 45.90 degrees postPPGT ( p < 0.0001). The postOPGT HA averaged 48.71 degrees with no statistically significant gain compared with postPPGT ( p = 0.21). The muscular portion of gracilis origin was cut to an average of 91.95 %; completely in only 14 hips, between 90 and 100 % in 35 hips, between 70 and 90 % in 9 hips, and between 60 and 70 % in 1 hip. The gain in HA did not correlate with the extent of the muscular portion sectioned percutaneously ( R = −0.043). Minimal accidental section of adductor brevis postPPGT was encountered in 39 hips. Considerable bleeding postPPGT with hematoma formation requiring hemostasis during the open control procedure occurred in 30 hips. Partial iatrogenic injury of the anterior branch of the obturator nerve was encountered in one patient bilaterally with severe adductor contracture, due to an anatomic too medial variant. Conclusions This is the only prospective study concerning the outcome of PPGT. Although PPGT is fast, simple and effective, it is not as safe as the open procedure even when performed correctly by an experienced surgeon, mainly because of the increased risk of bleeding. The findings of the current study do not support its use as a ‘standard-of-care’ technique in children with hip adductor contracture. Level of evidence Level II therapeutic study—prospective comparative study.

Introduction The purpose of this paper was to evaluate the results on shoulder function following isolated proximal subscapularis release in children with Erb's palsy. Methods A retrospective study was conducted on 64 consecutive children with Erb's palsy who underwent a Carlioz proximal subscapularis release between 2001 and 2012. Fifty children with complete records and a minimum follow-up of 2 years were included for evaluation. Age at surgery ranged from 1.3 to 4.5 years (average 2.6 years). Preoperative active shoulder abduction/anterior elevation, active external and internal rotations as well as the Mallet score were compared with those found at 6 and 24 months postoperatively using the Student paired t test, with a confidence interval of 95 %. The results were compared between children Results Active abduction improved 21° at 6 months and 31° (total) at 2 years ( p < 0.01) with an overall Mallet abduction score improvement of 0.58 at 6 months and 0.6 (overall) at 2 years ( p < 0.01). Active external rotation improved 52° at 6 months and 35° (total) at 2 years ( p < 0.01) with an overall Mallet external rotation score improvement of 1.3 at 6 months ( p < 0.01) and 0.52 (overall) at 2 years ( p = 0.013). There was no statistically significant change in internal rotation ( p = 0.37). We found no correlation between the child's age or the severity of involvement at surgery and the end result. Conclusion Proximal subscapularis release according to Carlioz is simple and effective in improving overall shoulder function in children with obstetric brachial plexus palsy, mainly abduction and external rotation. Improvement tends to reach a plateau around 6–12 months postoperatively.

Purpose of review Provide the reader with an evidence-based update on the importance of accurate diagnosis of commonly missed avulsion fractures of pelvis apophyses, the necessary imaging studies, the feared complications and the recent treatment recommendations. Recent findings Accurate diagnosis of avulsion fractures of pelvis apophyses is high yield as misdiagnosis leads to improper treatment. They should be differentiated from muscle strain and apophysitis. These fractures are usually associated with good outcomes; however, missed diagnosis can lead to further displacement, nonunion, functional limitation, femoroacetabular impingement and infection. A/P and frog lateral pelvis radiograph show the fracture and its displacement in the majority of cases. Conservative treatment, consisting of a short period of rest and immobilization followed by passive stretching then progressive resisted activity before return to sports, is recommended in minimally displaced avulsions. Surgical treatment is favored in displaced fractures (>15 mm), as it is associated with quicker return to sports. Summary Treating physicians should keep a high index of suspicion in pediatric and adolescent patients presenting with typical clinical exam findings. Pelvic Anteroposterior and frog leg radiographs are often diagnostic. Missed diagnosis can aggravate the prognosis of a usually benign condition. Adequate medical or surgical treatment should then be administered.

OBJECTIVEThe Ames–International Spine Study Group (ISSG) classification has recently been proposed as a tool for adult cervical deformity evaluation. This classification includes three radiographic cervical sagittal modifiers that have not been evaluated in asymptomatic adults. The aim of this study was to determine whether the sagittal radiographic modifiers described in the Ames-ISSG cervical classification are encountered in asymptomatic adults without alteration of health-related quality of life (HRQOL).METHODSThe authors conducted a cross-sectional study of subjects with an age ≥ 18 years and no cervical or back-related complaints or history of orthopedic surgery. All subjects underwent full-body biplanar radiographs with the measurement of cervical, segmental, and global alignment and completed the SF-36 HRQOL questionnaire. Subjects were classified according to the sagittal radiographic modifiers (chin-brow vertical angle [CBVA], mismatch between T1 slope and cervical lordosis [TS-CL], and C2–7 sagittal vertical axis [cSVA]) of the Ames–ISSG classification for cervical deformity, which also includes a qualitative descriptor of cervical deformity, the modified Japanese Orthopaedic Association (mJOA) myelopathy score, and the Scoliosis Research Society (SRS)–Schwab classification for spinal deformity assessment. Characteristics of the subjects classified by the different modifier grades were compared.RESULTSOne hundred forty-one asymptomatic subjects (ages 18–59 years, 71 females) were enrolled in the study. Twenty-seven (19.1%) and 61 (43.3%) subjects were classified as grade 1 in terms of the TS-CL and CBVA modifiers, respectively. Ninety-eight (69.5%) and 4 (2.8%) were grade 2 for these same respective modifiers. One hundred thirty-six (96.5%) subjects had at least one modifier at grade 1 or 2. There was a significant relationship between patient age and grades of TS-CL (p < 0.001, Cramer’s V [CV] = 0.32) and CBVA (p = 0.04, CV = 0.22) modifiers. The HRQOL, global alignment, and segmental alignment parameters were similar among the subjects with different modifier grades (p > 0.05).CONCLUSIONSThe CBVA and TS-CL radiographic modifiers of the Ames-ISSG classification do not seem to be specific to subjects with cervical deformities and can occur in asymptomatic subjects without alteration in HRQOL.

International audience; Aim: To estimate the effect of patients' axial rotation (AR) during pelvic radiograph acquisition, on the reliability and validity of sagittal pelvic parameters.Materials and methods: Lateral digitally reconstructed radiographs (LDRRs) were obtained from the pelvic computed tomography (CT) scans of eight children and nine adults. Then, the AR of the pelvis was simulated and the corresponding LDRRs were reconstructed at 5°, 10°, 15°, and 20° of the AR. Pelvic parameters were measured digitally on each radiograph. Intra- and interobserver variability were evaluated at each AR position (three operators repeated the measurements three times each). The bias on each clinical parameter, in each AR position, was calculated relatively to the 0° position.Results: Interobserver variability increased similarly in children and adults with AR. It reached 4.4° for pelvic incidence and 4.7° for the sacral slope at 20° of AR. Biases on radiological parameters increased with AR and exceeded the acceptable threshold of errors when AR reached 10°. A linear regression was established (R2=0.834, p

Chronic infection (CO) and infected non-union of the long bones are relatively rare conditions in paediatric patients. Large bone defects secondary to these conditions can be managed with the induced membrane technique. The technique requires grafting of the bone void, although it is not yet established what bone substitute is the best option. The aim of this work was to evaluate the outcome and efficacy of treatment in children with CO and infected non-union of the long bones using the induced membrane technique and bone (BG) versus beta-tricalcium phosphate (BTP) grafting. Eight skeletally immature patients with CO and infected non-union of the long bones were treated surgically between 2010 and 2017 by a combination of resection of necrotic infected bone, debridement of surrounding soft tissue, osteosynthesis using a stable internal fixation when needed, and application of antibiotic-laden cement (ALC) spacer inducing new membrane before final bone reconstruction with bone substitutes: BTP in five cases, BG (allograft and/or autologous graft) in three cases. A second surgical step, once inflammatory markers had normalized, consisted of ALC spacer removal, application of BG or BTP graft and concomitant stable osteosynthesis, if needed, if this had not been done during the first surgical stage. All the patients underwent clinical, laboratory and imaging evaluation before and after surgery. Antibiotics were adjusted according to culture and sensitivity. Mean patient age at time of diagnosis was 13 ± four years (range, 4–16) and all had at least a 12-month follow-up (range 12–60). Estimated time for induced membrane formation was significantly shorter in patients treated with BTP compared with BG: 3±1 vs. 10±2 (p = 0.02). This result was confirmed by multivariate analysis (p = 0.044) taking into account adjustment for age of patients and time after initial surgery. Time of final union was about 5.5 ± 4.1 months (range 2–66). At the last follow-up visit, bone had healed and all the patients had resumed daily living and sports activities. The induced membrane technique with BG or BTP graft can achieve bone healing in large bone defects secondary to CO and infected non-union in children and adolescents. The choice of bone substitute is important. Our preliminary results show graft integration and bone healing can be expected sooner if BTP is used as bone void filler.

Pediatric ganglion cyst of the hand is a rare entity. Its incidence is even lower in those arising from the metacarpophalangeal (MP) joint. We herein report the first known case of a ganglion cyst of the first MP joint in a 14-year-old boy. Pathogenesis, diagnosis and treatment are discussed.

Postural skeletal alignment is altered with age due to intervertebral disc and joint degeneration, consequently affecting quality of life (QoL) and activities of daily living, such as gait. Postural alignment parameters of the spine, pelvis, hips and lower limbs, measured on static standing radiographs, have been widely studied in asymptomatic subjects and subjects affected by various pathologies. However, while most of these parameters are positional and could vary during gait, there are currently no studies investigating how they are modified during walking.

Background Extensive wound dehiscence and wide plate and screw exposure in the early weeks following orthopaedic surgery in children is usually managed either by extensive debridement, lavage and secondary closure or hardware removal and external fixation. Patients Three children with LCP plate and screws exposure were managed by simple repetitive debridement and local wound care without any IV antibiotics, nor secondary closure or hardware removal. All three cases occurred in the tibia, one following tibial osteotomy in lateral hemimelia with a long history of previous surgeries, one following wide excision of a tibial Ewing sarcoma with chemo- and radiotherapy, and the third following wide excision of a 12 cm necrotic tibial segment due to chronic osteomyelitis. Bone healing was uneventful in 2 cases and was in progress in the case with the Ewing sarcoma. Plate and screws were removed in all cases, following an obvious bone healing in 2 cases, and forced by the need for chemotherapy due to the presence of lung metastases in the third case. Spontaneous soft tissue healing occurred thereafter. Conclusion A stable fixation may lead to a good bone healing despite an extensive wound dehiscence and a wide plate and screws exposure with just a proper local wound care and without any major additional surgery. Level of evidence Level IV.

The aim of this article is to describe a minimally invasive iliac crest-sparing approach (ICSA) allowing common iliac osteotomies in children. The ICSA was used for 98 hips in 72 consecutive patients who underwent a pelvic osteotomy. The mean follow-up duration ranged from 3 to 7 years. Skin incision ranged from 3 to 5.5 cm. Displacement of the distal osteotomy fragment was easy and without tension. The duration of surgery varied from 50 min in the beginning of our experience to 20-25 min for the last cases of the series. In conclusion, the ICSA fulfills all the criteria of minimally invasive surgery.

International audience; Cerebral palsy (CP) is a neurological disorder which can cause muscular spasticity. Children with this condition suffer from a combination of gait deviations, skeletal deformities and muscular abnormalities. Precise evaluation of each of these three components is crucial for management planning in children with CP. The aim of this study is to review the latest innovative methods used for three-dimensional (3D) gait analysis and musculoskeletal modeling in children with cerebral palsy. 3D gait analysis is a quantitative objective method based on the use of infrared cameras. It allows the evaluation of dynamic joint angles, forces and moments applied on joints and is usually coupled with dynamic electromyography. Skeletal evaluation is usually based on two-dimensional X-rays and physical examination in clinical practice. However, a novel method based on stereoradio-graphic 3D reconstruction of biplanar low dose X-rays allows a more thorough evaluation of skeletal deformities, and in particular torsional anomalies. Muscular evaluation of children with CP is most commonly based on magnetic resonance imaging, whereby delimitation of lower limb muscles on axial slices allows 3D reconstruction of these muscles. Novel innovative techniques allow similar reconstructions by extrapolation, thus limiting the necessary quantity of axial slices that need to be manually delimitated.; La paralysie cérébrale (PC) est un syndrome neurologique qui peut causer une spasticité musculaire. Les enfants ayant ce syndrome souffrent d’une combinaison de troubles de la marche, déformations squelettiques et anomalies musculaires. L’évaluation précise de chacune de ces trois composantes est cruciale dans la prise en charge des enfants ayant une PC. Le but de cette étude est de passer en revue les méthodes innovatrices utilisées pour l’analyse de la marche tridimensionnelle (3D) et la modélisation musculo- squelettique chez les enfants ayant une PC. L’analyse quantifiée de la marche permet l’évaluation des angles dynamiques articulaires, des forces et moments articulaires et est couplée à une électromyographie dynamique. L’évaluation squelettique est habituellement basée sur des radiographies bidimensionnelles et l’examen clinique. En revanche, une nouvelle méthode basée sur une reconstruction 3D stéréo-radiographique des radiographies biplanaires à basse dose d’irradiation permet l’évaluation des troubles de torsion. L’évaluation musculaire des enfants ayant une PC est le plus souvent basée sur l’imagerie par résonance magnétique, durant laquelle la délimitation des contours musculaires des membres inférieurs sur les coupes axiales permet la reconstruction musculaire en 3D. Une méthode innovatrice permet des reconstructions musculaires grâce à des extrapolations, limitant ainsi le nombre nécessaire de coupes axiales à délimiter manuellement.

Purpose The active or aggressive character in certain localisations of aneurysmal bone cysts in children requires either curettage with a considerable recurrence rate or a radical segmental excision, raising complex reconstructive challenges. Cyst maturation with subsequent ossification may be observed either spontaneously or after incisional biopsy. Patients Five new cases of active aneurysmal bone cysts (ABCs) with healing of the cyst after biopsy alone are reported. All patients had no treatment of the cyst after the biopsy. Results In two cases, the lesion initially increases in size immediately after the biopsy, and it is only secondarily that the lesion decreases in size. Four out of five cases of the spontaneous healing occurred in pelvic bone. The cysts healed after, respectively, 36, 24, 12, 32 and 12 months. Conclusions The emergence of these new cases of spontaneous healing encourages promoting clinical and radiological supervision after biopsy in selected cases. Unfortunately, it is impossible to predict a possible aggressive behaviour in ABCs. Then, if the lesion is quickly aggressive with clinically and radiologically increasing size after biopsy, it would be illogical and dangerous to let this ABC evolve. It would be necessary to treat it without delay. On the other hand, if the lesion moderately increased after the biopsy, it is possible to wait and observe the patient during a period of 5 months for a possible healing, if the ABC localisation is not dangerous. Of course, if the lesion does not increase in size after biopsy, there is no delay to treat it.

Tumoral calcinosis (TC) is a rare condition involving large joints and rarely the spine. It is characterized by calcification and swelling of periarticular tissues. Caffey disease (CD) is defined by recurrent episodes of painful soft tissue swelling and cortical thickening of the underlying bones. It is a self-limited disease that occurs in the first year of life. We report the first association of CD and TC of the cervical spine in a 4-month-old boy. We suggest that TC occurred as a consequence of the repetitive reparative process that takes place in CD, adding the latter to the list of diseases that may secondarily produce TC.