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Unlabelled: The Universal Clamp (UC) equipped with a soft sublaminar band is a relatively new thoracic anchor that can be used in hybrid constructs. A dedicated reduction tool that applies traction to the sublaminar band permits gentle translation of the thoracic curve to the pre-contoured fusion rods, which have been previously anchored distally by pedicle screws and proximally by hooks in a claw configuration., Methods: A literature review concerning the use of UC in adolescent idiopathic Scoliosis was performed., Results: The results confirm the efficacy with the UC hybrid constructs, the good correction (71-66%) of the main thoracic curve and low loss of correction at 2-year follow-up (3-4%). The thoracic curve correction achieved and maintained in the AIS patients appears to be substantially higher than that reported for all hook and hook hybrid techniques. Regardless of the deformity correcting method employed with all-screw constructs, the Cobb angle correction achieved is equivalent to that achieved with UC hybrid devices. Among the present AIS patients who had normal values of thoracic kyphosis pre-operatively, there was almost no change in average thoracic kyphosis at the latest follow-up. However, among the patients with low pre-operative values of T5-T12 kyphosis, the average T5-T12 kyphosis improved., Conclusion: Hybrid construct with UC is safe, with reduced operative time and blood loss. While achieving deformity correction in the coronal and axial planes equivalent to the best-reported results of all screw or previous hybrid constructs, the UC hybrid technique appears to provide superior correction in the sagittal plane. The excellent outcome is maintained at the 2-year follow-up.

Background: Determining patellar orientation in the transverse plane during observational gait analysis is a fundamental aspect of physical examinations. Many physicians consider that an abnormal position of the patella in the transverse planes is only explained by a rotational abnormality of the proximal femur., Methods: A total of 188 spastic diplegic children with cerebral palsy were reviewed (376 lower limbs). The physical examination included observation of patellar orientation at midstride and measuring femoral anteversion (FA). All patients also underwent 3-dimensional (3D) computerized gait analysis of pelvic and hip rotation kinematics., Results: Observational gait analysis and videotapes found 103 children (206 lower limbs) with inturned patella at midstance. Kinematic data from 3D gait analysis showed that the visual impression of turned inward patella was erroneous in 48 limbs. Of the remaining 158 lower limbs, 117 (74%) exhibited excessive FA and 41 (26%) did not. Of the 117 with excessive FA, kinematics showed only 66 (56%) with excessive internal hip rotation (with or without excessive internal pelvic rotation). Of the 41 lower limbs without excessive FA, 25 were explained by excessive internal pelvic rotation and 16 were explained by excessive internal hip rotation (isolated spasticity and/or contracture of internal rotator muscles). Turned inward patella was caused by isolated excessive internal pelvic rotation in 48%, excessive internal hip rotation in 35% (including 44 cases with excessive FA and 12 cases with isolated spasticity and/or contracture of internal hip rotators), and excessive internal hip rotation combined with excessive internal pelvic rotation in 17%., Conclusions: Excessive FA was not the only cause of turned inward patella gait and could not explain this gait anomaly by itself. Excessive internal pelvic rotation was the most frequent cause of turned inward patella gait., Level of Evidence: Level IV.

Purpose: Hip subluxation is common in children with cerebral palsy (CP). Surgery is indicated in case of pain or progressive increase of Reimers index on radiographs. Peri-iliac osteotomy combined with femoral osteotomy is one of the numerous operative techniques available, but results at skeletal maturity remain unclear. The purpose of this radiological study was to report the long-term results of this procedure., Materials and Methods: Twenty hips in 20 children were retrospectively evaluated at skeletal maturity. Mean age at surgery was 8.1 years and follow-up averaged 9.1 years. All patients underwent Dega acetabuloplasty, soft-tissue release and femoral-shortening varus derotation osteotomy without open reduction. Reimers index, acetabular angle (AA) and neck-shaft angle (NSA) were compared on preoperative, postoperative and latest follow-up radiographs., Results: Dega osteotomy significantly improved the AA and the correction remained stable at maturity. The NSA significantly decreased postoperatively (153°-115°), but recurrence of the valgus deformity (130°) of the proximal femur was observed at maturity. Consequently, Reimers index followed the same evolution. No case of osteonecrosis was reported but one hip dislocated and one subluxated during follow-up., Conclusion: Progressive recurrence of the valgus deformity of the proximal femur, attributable to adductors spasticity and gluteus medius weakness, led to a significant increase in the Reimers index. However, hip coverage remained >70 % at maturity in 90 % of the hips. This one-stage procedure without hip dislocation efficaciously corrected acetabulum dysplasia and successfully treated neurological hips in CP patients., Level of Evidence Iv: retrospective study.

Introduction: Lower limb torsion varies substantially among healthy children during growth. Values reported in the literature to date have been obtained using semi-quantitative clinical or 2D measurement methods. Quantitative 3D measurement would help determine the physiological range of lower limb torsion. Low-dose stereoradiography with 3D reconstruction provides a good alternative. Its use increases in pediatrics because of radiation minimization. Previous studies have shown accurate and reproducible results of lower limbs reconstruction in adults and children but the torsional parameters haven't been measured yet. The present study reports the values of lower limb segmental torsion and its course during growth in a cohort of healthy children and young adults using the EOS low-dose biplanar X-ray., Hypothesis: EOS 3D reconstruction is an accurate and reproducible method to measure the torsional parameters in children., Materials and Methods: Femoral torsion (FT) and tibial torsion (TT) were studied on 114 volunteers (228 lower limbs) from 6 to 30 years of age divided by age into 5 groups. The EOS™ acquisitions were obtained in subjects standing with their feet offset., Results: Mean FT decreased during growth, passing from 21.6° to 18°, whereas mean TT increased from 26.8° to 34.7°. There was a statistically significant difference between the 2 extreme age groups, but no difference was found between any other age groups. The ICC for intra-observer reproducibility was 0.96 and 0.95 for FT and TT for the first operator, and 0.79 and 0.83 for the second operator respectively. The ICC for inter-observer reproducibility was 0.84 and 0.82 respectively., Discussion: The course of lower limb segmental torsion observed was consistent with literature reports based upon clinical and 2D measurements. 3D reconstruction of EOS low-dose biplanar imaging appears to be a safe and reliable tool for lower limbs measurements, especially for investigating lower limb segmental torsion in children and adults., Level of Evidence: Level IV., (Copyright © 2013. Published by Elsevier Masson SAS.)

Study Design: Outcome study to determine the internal consistency, reproducibility, and concurrent validity of the French-Canadian version of the Scoliosis Research Society 22 (SRS-22 fcv) patient questionnaire in France., Objective: To determine whether the SRS-22 fcv can be used in a population from France., Summary of Background Data: The SRS-22 has been translated and validated in multiple countries, notably in the French-Canadian language in Quebec, Canada. Use of SRS-22 fcv seems appropriate for evaluating adolescent idiopathic scoliosis in France. However, French-Canadian French is noticeably different from the French spoken in France, and no study has investigated the use of a French-Canadian version of a health-quality questionnaire in another French population., Methods: The methods used for validating the SRS-22 fcv in Quebec were adopted for use with a group of 200 adolescents with idiopathic scoliosis and 60 healthy adolescents in France. Reliability and reproducibility were measured by the Cronbach α and intraclass correlation coefficient (ICC), construct validity by factorial analysis, concurrent validity by the Short-Form of the survey, and discriminant validity by analysis of variance and multivariate linear regression., Results: In France, the SRS-22 fcv showed good global internal consistency (Cronbach α = 0.87, intraclass correlation coefficient = 0.92), a coherent factorial structure, and high correlation coefficients between the SRS-22 fcv and Short-Form of the survey (P < 0.001). However, reliability and validity were slightly less than that for the instrument's original validation and the validation of the SRS-22 fcv in Quebec. These differences could be explained by language and cultural differences., Conclusion: The SRS-22 fcv is relevant for use in France, but further development and validation of a specific French questionnaire remain necessary to improve the assessment of functional outcomes of adolescents with scoliosis in France., Level of Evidence: N/A.

Backgrounds: With the development of molecular biology and specific polymerase chain reaction, Kingella kingae has become the primary diagnosis of osteoarticular infections in young children. Clinical features of these osteoarticular infections are typically mild, and outcome is almost always favorable. We report a series of unusually severe cases of K. kingae osteoarticular infections., Methods: All patients with severe osteoarticular infections at presentation were reviewed retrospectively in 2 European pediatric centers. K. kingae was identified using real-time polymerase chain reaction in blood, fluid joint or osseous samples. Clinical, laboratory tests and radiographic data during hospitalization and follow-up were analyzed., Results: Ten children (mean age 21 ± 12 months) with severe osteoarticular infections caused by K. kingae were identified between 2008 and 2011. Diagnostic delay averaged 13.2 ± 8 days. Only 1 patient was febrile at admission, and 50% children had normal C-reactive protein values (≤10 mg/dL) at presentation. Surgical treatment was performed in all cases. Intravenous antibiotic therapy by cephalosporins for an average of 8 ± 6 days was followed by oral treatment for 27 ± 6 days. Mean follow-up was 24.8 ± 9 months, and satisfactory outcomes were reported in all cases. Two patients (20%) developed a central epiphysiodesis of the proximal humerus during follow-up, but without significant clinical consequence for the moment., Conclusions: Because of their mild clinical features at onset, diagnosis of K. kingae osteoarticular infections can be delayed. Care should be taken for early detection and treatment of these infections because bony lytic lesions and potentially definitive growth cartilage damage can occur.

Background: Hematogenous osteoarticular infections of the hand and the wrist in children with sickle cell anemia are rare and no specific studies for this location have been published., Methods: This retrospective and comparative study reviewed 34 children who carry the diagnosis of osteoarticular infections of the wrist and the hand at our institution during a 10-year period extending from January 2000 to December 2010. The first group included 8 patients with sickle cell anemia (Hg SS). The second group or control group included 26 children without sickle cell disease or any immune deficiency. Differences between groups were established by χ tests., Results: The most common site of osteomyelitis for the sickle cell group was the metacarpals and the fingers phalanx (87.5%) whereas the most common site for the control group was the wrist and the carpus (96.2%; P<0.005).The most common pathogens responsible for osteomyelitis was Salmonella sp. (37.5%) for children with SCD, whereas it was Staphylococcus aureus (70%) for the nonsicklers. There was a significant difference between both groups regarding the treatment. Indeed, a surgical procedure was needed for the sickle cell group in all cases (100%) whereas a surgical debridement was needed in only 19.2% patients in the control group (P<0.001). At long-term follow-up, there were more long-term complications in the sickle cell group (62.5%) with epiphysiodesis of the metacarpals and metacarpophalangeal joint destruction whereas only 11.5% cases with complications were present in the control group including distal ulna epiphysiodesis, proximal interphalangeal joint stiffness, and a central radius epiphysiodesis (P<0.004)., Conclusions: Our results confirm the severity of hand osteomyelitis in patients with sickle cell disease. A systematic approach is needed to perform early diagnosis and treatment. Identification of the causative organism is required (blood culture, bone aspiration). With antibiotic therapy, surgical treatment is the rule. Parents have to be advised about frequent complications like shortening or deformation due to premature fusion., Level of Evidence: Level III.

Purpose: Computed tomography can be used for three-dimensional (3D) evaluation of adolescent idiopathic scoliosis (AIS) patients, but at the expense of high radiation exposure, and with the limitation of being performed in the supine position. These drawbacks can now be avoided with low-dose stereoradiography, even in routine clinical use. The purpose of this study was to determine the 3D postoperative correction of AIS patients treated by posteromedial translation., Methods: Forty-nine consecutive patients operated for AIS (Lenke 1-4) using posteromedial translation were included. Corrections were evaluated preoperatively, postoperatively and after at least 2 years using the EOS imaging system. 3D angles were measured in the plane of maximum deformity., Results: Mean number of levels fused and operative time were 13.5 ± 1 and 215 ± 25 min, respectively. Main thoracic, proximal thoracic, and lumbar curves corrections averaged 64.4 ± 18, 31 ± 10 and 69 ± 20 %, respectively. Mean T4-T12 kyphosis increased 18.8° ± 9° in the subgroup of hypokyphotic patients. Mean apical vertebral rotation reduction was 48.3 ± 20 %. Trunk height gain averaged 27.8 ± 14 mm. There was no pseudarthrosis or significant loss of correction in any plane during follow-up. Two patients (4 %) developed asymptomatic proximal junctional kyphosis, despite having normal thoracic kyphosis. Their sagittal balance was shifted posteriorly by 36 and 47 mm, respectively, by the operation, but revision surgery was not performed., Conclusions: Low-dose stereoradiography provided 3D reconstructions of the fused and unfused spine in routine clinical use. Postoperative 3D analysis showed that posteromedial translation enhanced sagittal balance correction, without sacrificing frontal or axial correction of the deformity.

Purpose: The spinal penetration index (SPI) quantifies the portion of the rib cage occupied by vertebrae. When measured by computed tomography (CT) or magnetic resonance imaging, SPI can only be determined in the reclining position, which modifies spinal and thoracic morphology. CT results in high radiation exposure. The authors studied rib cage and spinal morphology using low-dose biplanar stereoradiography and their impact on respiratory function in adolescent idiopathic scoliosis (AIS)., Methods: In eighty thoracic AIS patients, a slot-scanning radiologic device allowing simultaneous acquisition of orthogonal images and 3D reconstructions with low exposure to radiation (EOS) was used to determine thoracic volume, mean spinal penetration index (SPIm), apical spinal penetration index (SPIa), main thoracic (MT) curve Cobb angle, T4-T12 kyphosis, and apical vertebral rotation (AVR)., Results: Thoracic volume was correlated with thoracic kyphosis (r = 0.31, p = 0.006), but not with SPI, MT Cobb angle, or AVR. SPIm and SPIa were negatively correlated with thoracic kyphosis. Forced vital capacity and forced expiratory volume in 1 s were significantly lower in the hypokyphotic patients (p = 0.04, p = 0.03, respectively) and correlated with thoracic volume and T4-T12 kyphosis. No correlation was found between spinal penetration indices and pulmonary function tests, but SPIm was significantly greater in patients with obstructive syndrome (p = 0.01)., Conclusions: With little radiation exposure, EOS biplanar stereoradiography permits routine imaging is a functional standing position. Hypokyphotic patients had significantly decreased FEV1 and FVC. SPIm was significantly higher in patients with obstructive syndrome.

We describe two atypical cases of Kingella kingae infection in children diagnosed by PCR, one case involving a soft tissue abscess and one case a femoral Brodie abscess. Both patients had concomitant human rhinovirus infection. K. kingae strains, isolated from an oropharyngeal swab, were characterized by multilocus sequence typing and rtxA sequencing.

Purpose: To determine whether motion preservation following oblique cervical corpectomy (OCC) for cervical spondylotic myelopathy (CSM) persists with serial follow-up., Methods: We included 28 patients with preoperative and at least two serial follow-up neutral and dynamic cervical spine radiographs who underwent OCC for CSM. Patients with an ossified posterior longitudinal ligament (OPLL) were excluded. Changes in sagittal curvature, segmental and whole spine range of motion (ROM) were measured. Nathan's system graded anterior osteophyte formation. Neurological function was measured by Nurick's grade and modified Japanese Orthopedic Association (JOA) scores., Results: The majority (23 patients) had a single or 2-level corpectomy. The average duration of follow-up was 45 months. The Nurick's grade and the JOA scores showed statistically significant improvements after surgery (p < 0.001). 17% of patients with preoperative lordotic spines had a loss of lordosis at last follow-up, but with no clinical worsening. 77% of the whole spine ROM and 62% of segmental ROM was preserved at last follow-up. The whole spine and segmental ROM decreased by 11.2° and 10.9°, respectively (p ≤ 0.001). Patients with a greater range of segmental movement preoperatively had a statistically greater range of movement at follow-up. The analysis of serial radiographs indicated that the range of movement of the whole spine and the range of movement at the segmental spine levels significantly reduced during the follow-up period. Nathan's grade showed increase in osteophytosis in more than two-thirds of the patients (p ≤ 0.01). The whole spine range of movement at follow-up significantly correlated with Nathan's grade., Conclusions: Although the OCC preserves segmental and whole spine ROM, serial measurements show a progressive decrease in ROM albeit without clinical worsening. The reduction in this ROM is probably related to degenerative ossification of spinal ligaments.

Study Design: Radiological reproducibility study., Purpose: To assess intra and interobserver reliability of radiographic measurements for global sagittal balance parameters and sagittal spine curves, including cervical spine. Sagittal spine balance in adolescent idiopathic scoliosis (AIS) is a main issue and many studies have been reported, showing that coronal and sagittal deformities often involve sagittal cervical unbalance. Global sagittal balance aims to obtain a horizontal gaze and gravity line at top of hips when subject is in a static position, involving adjustment of each spine curvature in the sagittal plane. To our knowledge, no study did use a methodologically validated imaging analysis tool able to appreciate sagittal spine contours and distances in AIS and especially in the cervical region., Methods: Lateral full-spine low-dose EOS radiographs were performed in 75 patients divided in three groups (control subjects, AIS, operated AIS). Three observers digitally analyzed twice each radiograph and 11 sagittal measures were collected for each image. Reliability was assessed calculating intraobserver Pearson's r correlation coefficient, interobserver intra-class correlation coefficient (ICC) completed with a two-by-two Bland-Altman plot analysis., Results: This measurement method has shown excellent intra and interobserver reliability in all parameters, sagittal curvatures, pelvic parameters and global sagittal balance., Conclusions: This study validated a simple and efficient tool in AIS sagittal contour analysis. It defined new relevant landmarks allowing to characterize cervical segmental curvatures and cervical involvement in global balance.

Purpose: To analyze postoperative changes in the cervical sagittal alignment (CSA) of patients with AIS treated by posteromedial translation., Methods: 49 patients with thoracic AIS underwent posterior arthrodesis with hybrid constructs, combining lumbar pedicle screws and thoracic universal clamps. Posteromedial translation was the main correction technique used. 3D radiological parameters were measured from low-dose biplanar radiographs. CSA was assessed using the C2C6 angle, and the central hip vertical axis (CHVA) was used as a reference axis to evaluate patients' balance., Results: Preoperatively, 58 % of patients had thoracic hypokyphosis, and 79 % had a kyphotic CSA. Significant correlation was found (r = 0.45, P = 0.01) between thoracic hypokyphosis and cervical kyphosis. Increase in T4-T12 thoracic kyphosis (average 14.5° ± 10°) was associated with significant decrease in cervical kyphosis in the early postoperative period. The CSA further improved spontaneously during follow-up by 7.6° (P < 0.0001). Significant positive correlation (r = 0.32, P = 0.03) was found between thoracic and cervical improvements. At latest follow-up, 94 % of the patients were normokyphotic and 67 % had a CSA in the physiological range. Sagittal balance of the thoracolumbar spine was not significantly modified postoperatively. However, the procedure significantly changed the position of C2 in regard to the CHVA (C2-CHVA), which reflects headposition (P = 0.012). At last follow-up, the patients sagittal imbalance was not significantly different from the preoperative imbalance (P = 0.34)., Conclusions: Thoracic hypokyphosis and cervical hypolordosis, observed in AIS, can be improved postoperatively, when the posteromedial translation technique is used for correction. The cervical spine remains adaptable in most patients, but the proportion of patients with physiological cervical lordosis at final follow-up remained low (24.5 %).

We report two male sibs, born from unrelated French Caribbean parents, presenting with an unclassifiable storage disorder. Pregnancy and delivery were uneventful. Stunted growth was noted during the first year of life. Both children have short stature (below - 4SD) with short trunk, barrel chest, micromelia with rhizomelic shortening, severe kyphoscoliosis, pectus carinatum, short hands and feet with metatarsus adductus, and excessive joint laxity of the small joints. Learning difficulties with borderline intelligence quotient (IQ) were noted in one of them. They had no hepatomegaly, no splenomegaly, and no dysmorphism. Skeletal X-rays survey demonstrated generalized platyspondyly with tongue-like deformity of the anterior part of the vertebral bodies, hypoplasia of the odontoid process, generalized epiphyseal dysplasia and abnormally shaped metaphyses. The acetabular roofs had a trident aspect. Ophthalmologic and cardiac examinations were normal. Spine deformity required surgical correction in one of the patient at age 4 years. Lysosomal enzymes assays including N-acetylgalactosamine-6-sulfate sulfatase and β-galactosidase were normal, excluding mucopolysaccharidoses type IV A and IV B (Morquio syndrome), respectively. Qualitative analysis found traces of dermatan and chondroitin-sulfates in urine, but quantitative glycosaminoglycan excretion fell within normal limits. They were no vacuolated lymphocytes. Abnormal coarse inclusions were present in eosinophils. Mild Alder anomaly was observed in polymorphonuclears. Granulations were discretely metachromatic with toluidine blue. Those morphological anomalies are in favor of a lysosomal storage disease. No inclusions were found in skin fibroblasts. We hypothesize that these two boys have a distinct autosomal recessive or X-linked lysosomal storage disorder of unknown origin that shares clinical and radiological features with Morquio disease., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Background: Kingella kingae, a normal component of the upper respiratory flora, is being increasingly recognized as an important invasive pathogen in young children. Genetic diversity of this species has not been studied., Methods: We analyzed 103 strains from different countries and clinical origins by a new multilocus sequence-typing (MLST) schema. Putative virulence gene rtxA, encoding an RTX toxin, was also sequenced, and experimental virulence of representative strains was assessed in a juvenile-rat model., Results: Thirty-six sequence-types (ST) and nine ST-complexes (STc) were detected. The main STc 6, 14 and 23 comprised 23, 17 and 20 strains respectively, and were internationally distributed. rtxA sequencing results were mostly congruent with MLST, and showed horizontal transfer events. Of interest, all members of the distantly related ST-6 (n = 22) and ST-5 (n = 4) harboured a 33 bp duplication or triplication in their rtxA sequence, suggesting that this genetic trait arose through selective advantage. The animal model revealed significant differences in virulence among strains of the species., Conclusion: MLST analysis reveals international spread of ST-complexes and will help to decipher acquisition and evolution of virulence traits and diversity of pathogenicity among K. kingae strains, for which an experimental animal model is now available.

Segmental defects of the tibia are challenging therapeutic problems for both the physician and the patient. These defects may be caused by severe trauma, infection, tumors and congenital processes. Several different techniques have been described for treatment of these defects including the Papineau technique, allograft reconstruction, bone transport using the Ilizarov frame, free vascularized fibular graft, tibiofibular synostosis and medial transport of the fibula with Tuli's technique, use of the Ilizarov frame and Huntington's procedure. All of these techniques have their specific advantages as well as disadvantages. Some of these techniques are used rarely i.e. the Papineau technique. The procedure of choice for most large tibial defects is bone transport with Ilizarov's technique; but in some cases the tibial remnant is inadequate for lengthening and we must use alternative treatments. In the three aforementioned techniques, the fibula is transferred with peroneal and anterior tibial muscles on a pedicle of peroneal vessels. This transfer retains a biological component of vital bone that allows for a shorter time for consolidation, increased remodeling potential and resistance to infection. It also has better long-term mechanical properties. Hypertrophy of the centralized fibula is described as attaining twice its original diameter or twice the size of the contralateral tibia. Hypertrophy has been seen in nearly all cases of the fibular centralization. Maximum hypertrophy is seen in children and besides patient age, is related to bony union and weight bearing. The reported time for hypertrophy of fibula varies from one to four years. No significant change in the diameter of the fibula was observed after five years. Fracture of tibialized fibula was not reported in many studies of fibular centralization with different techniques. In the reviewed articles, there were no cases of valgus deformity of the ankle. Either the patients were satisfied with the final results despite appearance of the lower extremity and the presence of some angular deformities, although in most cases, the deformities were mild. In this review we conclude that tibialisation of the fibula in selected cases is a reasonable alternative for the treatment of massive tibial defects.

We conducted a retrospective study comparing the presenting clinical and biologic features of 64 children who had septic arthritis caused by Kingella kingae with 26 children who had septic arthritis caused by Staphylococcus aureus. Children with K. kingae septic arthritis were significantly younger than those with S. aureus septic arthritis. Otherwise, there were no significant differences between the 2 groups with respect to fever, location, white blood cell count, synovial fluid cell count, C-reactive protein, or serum fibrinogen. However, the clinical course was significantly better for children with septic arthritis caused by K. kingae as evidenced by shorter hospitalization and fewer adverse events. Presumptive antibiotic therapy for septic arthritis in young infants should take into account both of these pathogens, even in case of mild presentation.

Introduction: Severe forms of Blount's disease may be associated with medial tibial plateau (MTP) depression. Management should then take account of joint congruence, laxity, limb axis, torsional abnomality, leg length discrepancy (LLD) and eventual recurrence history., Patients and Methods: Eight knees (six patients) were managed in a single step comprising MTP elevation osteotomy, lateral epiphysiodesis and proximal tibia osteotomy to correct varus and rotational deformity. Fixation was achieved using an Ilizarov external fixator. Mean age was 10.5 years. Mean hip-knee-ankle (HKA) angle was 151°; distal femoral varus, 94°; metaphyseal-diaphyseal angle (MDA), 27°; and angle of depression of the medial tibial plateau (ADMTP), 42°. Predicted residual proximal tibial growth was 2.6 cm., Results: At a mean 48 months' follow-up, results were good in six cases, medium in one and poor (due to incomplete lateral epiphysiodesis) in one. Mean lateral tibial torsion was 9° and final LLD 11 mm. Weight-bearing was resumed at 2 months, and the fixator was removed at 5.5 months postoperatively. At end of follow-up, mean HKA angle was 179.6°, MDA 7.3° and ADMTP 5.4°., Discussion: This technically demanding procedure gave satisfactory results in terms of axes and congruence; longer term assessment remains needed., Level of Evidence: Level IV. Retrospective study., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Background: Thoracoscopy is now considered a safe and feasible method for surgical management of spinal disorders in both adults and children. Nevertheless, a weight less than 20 kg has been reported as a relative contraindication because of the small volume of the thoracic cage and the anticipated difficulties of single-lung ventilation. The aim of this study was to evaluate the feasibility, as well as the safety and efficacy, of thoracoscopic procedures in such patients., Methods: This study was a retrospective analysis of a consecutive group of patients less than 20 kg weight, who underwent a thoracoscopy between 1998 and 2005. Results were evaluated radiologically, and intraoperative and postoperative complications were reported. A minimum 2-year follow-up was required., Results: Seventeen patients were included. Age at surgery averaged 3 years and 4 months (±1.25). The mean weight was 13.3 kg (±2.8). Fourteen of the patients had congenital scoliosis, 9 due to hemivertebrae and 5 due to segmentation failures. The other 3 suffered from evolutive kyphosis, 2 caused by Pott disease, and 1 caused by congenital anterior failure of segmentation. The mean follow-up was 6 years and 9 months (±1.5). Lung exclusion time averaged 114 minutes (±20). The intended procedure was possible in all cases and no conversion to open thoracotomy was required. The mean operating time was 139 minutes (±10). A posterior arthrodesis was associated and performed during the same anesthesia in 15 cases. The selective breathing was efficient and well tolerated in all cases. No intraoperative respiratory complication was observed. For patients with congenital scoliosis, the average improvement of the main curve between preoperative and latest follow-up was 55%, with an average Cobb angle improvement of 19.1 degrees (±10.5). For the 3 cases of kyphosis, the curve progression stopped, with a mean reduction of the regional kyphosis of 6 degrees (±11.5). Fusion was obtained radiologically in all cases., Conclusions: This study confirms the feasibility, safety, and efficacy of thoracoscopy for the management of spinal disorders in children less than 20 kg weight. Thoracoscopy can still be considered as an option in very young children, even though the small chest cavity creates additional technical challenges and the diminutive bronchial tree necessitates a dedicated method of single-lung ventilation., Level of Evidence: IV.

Study Design: Retrospective study of prospectively collected data., Objective: Compare Universal Clamps (UCs) and hooks for the thoracic correction of adolescent idiopathic scoliosis (AIS)., Summary of Background Data: In scoliosis surgery, sagittal correction is as important as frontal correction due to the risk of junctional kyphosis. Compared to all-screw constructs, hybrid constructs with lumbar pedicle screws and thoracic hooks or sublaminar wires have been shown to achieve similar coronal correction while providing superior postoperative thoracic kyphosis. The authors used a novel sublaminar thoracic implant, the UC with improvements over sublaminar wires. Hybrid constructs using thoracic UCs were compared to those with thoracic hooks., Methods: This series involved 150 patients treated for AIS with hybrid constructs. A total of 75 consecutive patients operated from 2001 to 2003, who had thoracic hooks with in situ contouring, distraction, and compression (Group 1), were compared to 75 consecutive patients operated from 2004 to 2006, who had thoracic UCs with posteromedial translation (Group 2). All had intraoperative somatosensory/motor-evoked potential monitoring and at least 2-years follow-up., Results: Except for follow-up (longer in Group 1), the 2 groups were similar before surgery. The UCs achieved better thoracic coronal correction (P < 0.001), Cincinnati index (P < 0.001), kyphosis (P = 0.02), and apical rotation (P < 0.001). In normokyphotic or hypokyphotic patients, the UC corrected thoracic kyphosis by 11.2 degrees (55%) versus 0.4 degrees (2%) achieved by hooks (P < 0.0001). These differences were stable at last follow-up. There were no intraoperative complications or changes in somatosensory/motor-evoked potentials. UC reduced operative time by 20% (60 minutes; P < 0.001) and blood loss by 23% (250 mL; P < 0.001)., Conclusion: Although both of these hybrid constructs efficaciously corrected the coronal and axial deformities in AIS, the results of the UC technique were superior to those achieved with hooks in all 3 planes, especially the sagittal plane. Moreover, the UC technique is straightforward and safe, reducing both operative duration and blood loss.

Study Design: A literature-based review., Objective: To summarize the clinical and morphologic findings leading to diagnosis, the etiologic factors, and principles of management. To identify the strengths and limits of past studies., Summary of Background Data: There are considerable controversies regarding etiologic factors, diagnosis, and management of adjacent segment disease in patients instrumented for idiopathic scoliosis., Methods: Summarized is past literature and, to some extent, personal experience of the authors., Results: Several factors participating to this complex pathophysiology are reported. The clinical presentation, occurring after symptom free interval, can vary, and modern morphologic investigations help for diagnosis. Management is often surgical and remains challenging., Conclusions: Long-term consequences of spinal fusions are now major concerns, especially in young patients undergoing surgical correction for idiopathic scoliosis. Adjacent segment disease is defined by a combination of clinical symptoms and morphologic findings. Several etiologic factors have been reported, but need to be further studied to prevent and improve the surgical management of this complication.

Purpose: The development of claw toe deformity following fracture of the tibia in children has not been described in our review of the literature. We report on the management of the acquired claw toe deformity after tibia fracture in five children., Methods: We report on five patients, between 5 and 15 years of age, who developed clawing of the hallux following a fracture of the tibia. In two patients, the lesser toes were involved. On examination, when the ankle was passively plantar flexed, a flexion contracture of the interphalangeal joint of the hallux became fully flexible. When the ankle was dorsiflexed, the clawing became more obvious and fixed. A magnetic resonance imaging (MRI) study in two cases demonstrated fibrosis under or just proximal to the tarsal tunnel., Results: The contractures were relieved by performing a tenolysis proximal to the medial malleolus. The operative findings demonstrated that the etiology could be possibly associated with a localized subclinical compartment syndrome., Conclusions: We described five patients with a claw toe deformity following a tibia fracture associated with adhesions of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles to the surrounding structures under or just proximal to the flexor retinaculum. It is the authors' opinion that this condition may be related to a subclinical compartment syndrome localized in the distal part of the deep posterior compartment. Soft-tissue release without tendon lengthening allowed recovery in all patients.

Introduction: Several recent studies demonstrate that upper extremities kinematics analysis is in increasing use to assist clinical practice. We describe an upper limb kinematics analysis protocol that was first applied to a group of healthy children (to obtain normative data), and subsequently, to a child presenting with obstetrical brachial plexus palsy (OBPP) before and after surgical treatment., Materials and Methods: The protocol is based on two very simple tasks. Reflective markers are placed on the studied segments, and optoelectronic cameras three-dimensionally record the position of the markers during the course of movement. The data, collected by a Vicon system (Oxford Metrics Ltd., Oxford, UK), are analyzed by a dedicated software; this software provides coefficient of multiple correlation (CMC) for the comparison of different kinematics curves and motion amplitudes. A CMC above 0.95 was considered to be excellent, between 0.85 and 0.95 was good, and below 0.85 was poor. Twelve healthy children, average age 9.7 years (from 7 to 14 years), were analyzed. A 7-year-old patient presenting left OBPP was similarly analyzed, pre- and postoperatively, after a lateral rotation osteotomy of the humerus., Results: The analysis of the 12 healthy children established a kinematics corridor for each task and each angle considered. Analysis of the pathological patient revealed kinematics anomalies during movement which went undetected at simple clinical examination. CMC analysis after treatment showed improvement of all movements around the shoulder, going from "poor" preoperatively to "excellent" postoperatively. Amplitudes analysis similarly demonstrated postoperative improvement, which increased from 28 to 67% according to the rotations considered, around the shoulder and elbow. The interest in these results should be confirmed by studies in a larger number of patients., Discussion: Upper extremity kinematics analysis is increasingly utilized in current clinical practice. Although many problems occur because of the non-cyclical and non-automatic nature of movement, review of the literature and our preliminary results show that reproducibility is satisfactory. Interest in our work arises from helping develop a preoperative evaluation tool (providing a more global view of abnormalities) as well as a postoperative assessment one (for the quantification of movement gains obtained by surgery after humeral osteotomy)., Level of Evidence: Level IV. Diagnostic retrospective study., (2009 Elsevier Masson SAS. All rights reserved.)

State and local legislatures in more than twenty states have considered enacting fair share laws. Fair share laws typically require employers of a certain size either to spend a designated percentage of their total payroll costs on health insurance for their employees or pay into a state fund for uninsured individuals. Such laws have been challenged in the federal courts, ultimately resulting in differing decisions. In 2007, the Fourth Circuit Court of Appeals affirmed the lower court's decision to strike down the Maryland Fair Share Act, holding it was preempted by the Employee Retirement Income Security Act (ERISA). The Fair Share for Health Care Act in Suffolk County, NewYork succumbed to a similar fate. However, in the Ninth Circuit, San Francisco's Health Care Security Ordinance survived ERISA preemption. This article analyzes the Fourth and Ninth Circuit decisions and explores the potential effects of the differing outcomes on healthcare reform.

Inoculation of blood culture vials with joint fluid samples has revealed the important pathogenic role of Kingella kingae in pediatric arthritis. However, recent studies based on broad-range 16S ribosomal DNA PCR and real-time PCR without a probe suggest that conventional methods remain suboptimal. We developed a new real-time PCR method with a probe that is highly specific for K. kingae and applied it to joint fluid samples collected from 89 children with suspected arthritis admitted to our institution during a 2-year period. Real-time PCR was also applied to blood samples obtained before surgery and to joint drainage fluid samples obtained during several days after surgery. Thirty-six (40%) of the 89 cases of suspected septic arthritis had positive culture. Staphylococcus aureus was the main isolate (n = 19/36, 53%), followed by K. kingae (n = 7/36, 19%). Specific real-time PCR identified K. kingae in 24 of the 53 culture-negative cases. Thus, K. kingae was present in 31 (52%) of the 60 documented cases, making it the leading pathogen. Real-time PCR on all 15 blood DNA extracts from patients with K. kingae infection was negative, demonstrating that joint fluid positivity did not result from DNA circulating in blood. Real-time PCR amplification of drainage fluid samples showed that the pathogen could be detected for up to 6 days after antibiotic initiation. K. kingae real-time PCR applied to DNA extracted from joint fluid samples, but not from blood samples, markedly improved the etiological diagnosis of septic arthritis in children. Retrospective diagnosis is feasible for up to 6 days after treatment initiation.

Correction of adolescent idiopathic scoliosis (AIS) has been reported with various systems. All-screw constructs are currently the most popular, but they have been associated with a significant decrease in thoracic kyphosis, with a potential risk of junctional kyphosis, not observed with hybrid constructs in the literature. In addition, it is important to weigh potential advantages of pedicle screw fixation against risks specific to its use. Because hybrid constructs are associated with a lower risk of complications and better sagittal correction than all-screw constructs, at present we use lumbar pedicle screws combined with a new sublaminar connection to the spine (Universal Clamps) at thoracic levels. The purpose of this study was to determine the efficacy and safety of the Universal Clamp (UC) posteromedial translation technique for correction of AIS. Seventy-five consecutive patients underwent posterior spinal fusion and hybrid instrumentation for progressive AIS. Correction was performed at the thoracic level using posteromedial translation. At the lumbar level, correction was performed using in situ contouring and compression/distractions maneuvers. A minimum 2-year follow-up was required. Medical data and radiographs were prospectively analyzed and compared using a paired t test. The average age at surgery was 15 years and 4 months (+/-19 months). The average number of levels fused was 12+/-1.6. The mean follow-up was 30+/-5 months. The average preoperative Cobb angle of the major curve was 60 degrees+/-20 degrees. The immediate postoperative major curve correction averaged 66+/-13%. The average loss of correction of the major curve between the early postoperative assessment and latest follow-up was 3.5 degrees+/-1.4 degrees . The mean Cincinnati correction index was 1.7+/-0.8 postoperatively, and 1.57+/-1 at last follow up. The mean rotation of the apical vertebra was corrected from 23.3 degrees+/-9 degrees preoperatively to 7.3 degrees+/-5 degrees at last follow up (69% improvement, P<0.0001). In the sagittal plane, the mean thoracic kyphosis improved from 23.8 degrees+/-14.2 degrees preoperatively to 32.3 degrees+/-7.3 degrees at last follow up. For the 68 patients who had a normokyphotic or a hypokyphotic sagittal modifier, thoracic kyphosis increased from 20.5 degrees+/-9.9 degrees to 31.8 degrees+/-7.4 degrees, corresponding to a mean kyphosis correction of 55% at last follow up. No intraoperative complication occurred and none of the patients developed proximal junctional kyphosis during the follow up. The principal limitation of the UC technique was the rate of proximal posterior prominence (14.6%), leading us to recommend the use of conventional claws at the upper extremity of the construct. The technique was safe, and reduced operative time, radiation exposure, and blood loss. While achieving correction of deformity in the coronal and axial planes equivalent to the best reported results of all-screw or previous hybrid constructs, the UC hybrid technique appears to provide superior correction in the sagittal plane. The excellent outcome in all three planes was maintained at 2 year follow up.

Purpose of the Study: Determining the level of fusion remains a highly debated topic in adolescent isiopathic scoliosis. The King and Lenke classifications are used, but have their limitations, particularly the weak interobserver reproducibility. We describe the method we use which is independent of the anatomic classification, based on the predictable reduction of the different curvatures. The goal is to achieve good balance of T1 and the shoulders and reestablish spinal balance in the frontal and sagittal planes. The purpose of this work was to assess the midterm results of this strategy for determining the upper level of instrumentation., Material and Methods: The series included 103 adolescents who underwent surgery for idiopathic thoracic scoliosis using a posterior segmental instrumentation. The upper level of fusion was determined by analyzing the rigidity of the proximal curvature and the inclination of T1 and the shoulder. X-rays (preop, postop, last follow-up) were digitalized for computer processing. Comparisons were made with the t test for paired series., Results: Mean age at surgery was 15.2+/-1.7 years (range 10.8-19.3). Mean follow-up was 30.2 months. The clavicular angle and T1 inclination were improved significantly, both for the unique thoracic curvatures and for double thoracic curvatures. No correlation could be found between T1 inclination and shoulder balance. At last follow-up, 86.5% of the patients satisfied all balance criteria., Discussion: The results of our method, which was carried out fully in 97% of patients, are encouraging and show that systematic instrumentation of the entire proximal curvature is not warranted for double thoracic curvatures. The long-term consequences for the residual T1 inclination remain to be assessed.

The chromosomal replication cycle is strictly coordinated with cell cycle progression in Escherichia coli. ATP-DnaA initiates replication, leading to loading of the DNA polymerase III holoenzyme. The DNA-loaded form of the beta clamp subunit of the polymerase binds the Hda protein, which promotes ATP-DnaA hydrolysis, yielding inactive ADP-DnaA. This regulation is required to repress overinitiation. In this study, we have isolated a novel cold-sensitive hda mutant, the hda-185 mutant. The hda-185 mutant caused overinitiation of chromosomal replication at 25 degrees C, which most likely led to blockage of replication fork progress. Consistently, the inhibition of colony formation at 25 degrees C was suppressed by disruption of the diaA gene, an initiation stimulator. Disruption of the seqA gene, an initiation inhibitor, showed synthetic lethality with hda-185 even at 42 degrees C. The cellular ATP-DnaA level was increased in an hda-185-dependent manner. The cellular concentrations of DnaA protein and dnaA mRNA were comparable at 25 degrees C to those in a wild-type hda strain. We also found that multiple copies of the ribonucleotide reductase genes (nrdAB or nrdEF) or dnaB gene repressed overinitiation. The cellular levels of dATP and dCTP were elevated in cells bearing multiple copies of nrdAB. The catalytic site within NrdA was required for multicopy suppression, suggesting the importance of an active form of NrdA or elevated levels of deoxyribonucleotides in inhibition of overinitiation in the hda-185 cells. Cell division in the hda-185 mutant was inhibited at 25 degrees C in a LexA regulon-independent manner, suggesting that overinitiation in the hda-185 mutant induced a unique division inhibition pathway.

Purpose: Chiari medial displacement osteotomy is a procedure that uses the cancellous bone of the ilium to contain the femoral head and bear weight. It is the most contraversial osteotomy of the hip joint. This study was therefore conducted to determine the results of this osteotomy with mid-term follow-up in children., Methods: From 1995 to 2004, 20 Chiari pelvic osteotomies (in 18 patients) were performed. There were 15 male and 3 female patients. The average age at operation was 12.6 years and the mean follow-up was 54 months. The operative technique was as described by Chiari. An iliofemoral approach was used without utilizing a traction table. If there was anterior or anterolateral uncoverage of the femoral head, bone graft augmentation was performed., Results: The angle of the osteotomy averaged 12 degrees , with the distance from the acetabulum averaging 3.2 mm. The average displacement was 42%. Of the 20 Chiari osteotomies, 11 were categorized as excellent, 8 as good and one as fair in terms of clinical and radiological results. Student's t test statistics showed improvements in all radiologic parameters of the hip joint (Sharp angle, center-edge angle and coverage of the femoral head). Graft resorption was observed in 25% of the patients., Conclusion: There are very rare indications of Chiari osteotomy in patients younger than 10 years. Because of the high rate of graft resorption, Chiari osteotomy should be the last treatment option when there is anterior or anterolateral uncoverage of the hip joint.

Introduction: Wrist osteomyelitis is a rare infection, and few studies have been published about its prognosis and treatment., Methods: We retrospectively examined the medical records of 18 children older than 4 months who were diagnosed with wrist osteomyelitis. A definite diagnosis of wrist osteomyelitis required either confirmatory radiographic/bone scintigraphy changes associated with compatible clinical picture and elevated laboratory indices consistent with infection. The clinical evaluation was based on clinical and radiographic assessment at 1 week, 2 weeks, 3 months, 6 months, 1 year, and 2 years after the diagnosis., Results: Delay between initial symptoms and treatment ranged from 1 to 45 days (mean, 7 days). The radiographs at diagnosis demonstrated a lytic zone in the distal radial or ulnar metaphysis in 5 cases. All patients were treated with 6 weeks' course of antibiotics with sequential parenteral (7 days)-oral with a third-generation cephalosporin (Cefotaxim) associated with Fosfomycin. Surgical debridement was needed in 5 cases because plain radiographs, ultrasonography, or magnetic resonance imaging (MRI) had confirmed the presence of an intraosseous or subperiosteal abscess. Seven isolated organisms were methicillin-susceptible Staphylococcus aureus, and 1 was methicillin-resistant S. aureus. The average follow-up was 2 years. Significant orthopaedic sequelae as distal radius/ulna epiphysiodesis were apparent in 2 patients., Discussion: Wrist osteomyelitis is a severe infection with initial radiographic lytic zone in almost 30% of cases and with growth disturbance in 11% at the last follow-up. If we include the presence of intraosseous or subperiosteal abscess that required surgical debridement, the initial complication rate is 33%, which is superior to the 5% complication rate in the literature about general osteomyelitis. Misdiagnosis at initial clinical examination can explain this condition.

A retrospective study of 21 patients with idiopathic scoliosis who underwent endoscopic thoracoplasty was done. The objective of the study was to report and assess the morbidity and mid term outcomes of video-assisted thoracoplasty in idiopathic scoliosis. Patients with idiopathic scoliosis often present cosmetic complaints due to their rib deformity. This deformity may still exist after surgical correction of the main scoliotic curve. Endoscopic thoracoplasty has been reported as a safe method in limited cases of idiopathic scoliosis. Between 2002 and 2004, 21 patients underwent endoscopic anterior release and thoracoplasty for significant rib hump deformity associated with idiopathic scoliosis. Patients were operated on lateral position, with two endoscopic ports. Anterior release and rib resection were performed during the first stage, and instrumented posterior fusion was performed in a second stage. Patients were evaluated preoperatively, 1 week after surgery, 6 months after surgery and at their most recent follow-up with clinical and radiological measurement of the rib deformity. The mean age at surgery was 14.9 years old (range 13-17 years). The average Cobb's angle of the main scoliotic curve was 70 degrees (range 60 degrees -85 degrees). Average follow-up was 25 months (range 23-32 months). The mean number of resected ribs was five ribs (range 4-7) and the mean length of the resected rib was 4.2 cm (range 2.2-7 cm). Average operating time of endoscopic thoracoplasty (including anterior release) was 65 min (range 45-108 min). The mean preoperative height of rib hump deformity was 3.6 cm (range 2.5-5.5 cm). It was reduced to 1.5 cm at most recent follow-up. There was no significant thoracic pain necessitating medication postoperatively. No complications related to endoscopic anterior release and rib hump resection occurred in the series. Endoscopic thoracoplasty is a safe and reliable technique in idiopathic scoliosis. If indicated, the anterior release can be performed with video-assistance and the thoracoplasty can be performed on the same stage.

To describe a derotation calcaneal osteotomy technique and assess its efficacy in the correction of relapsed clubfoot. Twenty-one osteotomies were performed in 20 children with recurrent clubfoot. Nineteen children had been previously treated operatively. The derotation osteotomy was the first procedure performed in one case. The procedure combined medial and plantar releases, followed by a curvilinear osteotomy of the calcaneus. Patients were evaluated clinically and with standing dorsoplantar and lateral radiographs preoperatively, postoperatively and at follow-up. The talocalcaneal angle was considered as the most important criteria to evaluate the deformity correction. The clubfoot was idiopathic in 16 cases and neurological in five cases. Mean age at surgery was 7 years old (range 3.4-12 years). Total number of procedures per foot averaged 2.4 (range 4-1). The mean postoperative follow-up period was 2.8 years (range 2-6 years). The talocalcaneal angle increased significantly after the procedure (P<0.001), and no significant loss of correction was seen at latest follow-up (P=0.17). Two scarring complications occurred. Only one foot underwent further surgery after the calcaneal osteotomy for residual forefoot adduction, associated to a cavus and severe fibrosis. The calcaneal curvilinear osteotomy, in which the calcaneoforefoot unit derotation is performed around the talus but within the calcaneus, is a safe and efficient technique that can be proposed for clubfoot revision surgery.

The aim of this study is to describe a surgical procedure proposed for high-grade isthmic spondylolisthesis, with intraoperative reduction using Jackson's intrasacral fixation. The procedure is performed using a single posterior approach. The intraoperative correction of the deformity is obtained by sacral dome resection and reduction of the lumbosacral kyphosis using Jackson's fixation to rotate the sacrum. After sagittal balance restoration, L4-S1 circumferential fusion is performed with interbody cages. The technique is effective in the restoration of spinal and pelvic parameters of sagittal balance, and optimal conditions for fusion are obtained. The use of Jackson's intrasacral fixation provides the strong stability needed to correct the lumbosacral deformity, with little neurological risk during intraoperative reduction.

As states experiment with legislation designed to address problems of healthcare affordability and accessibility by requiring employers to offer or spend more on employee health benefit plans, courts increasingly will be called upon to determine whether such mandates run afoul of ERISA. This article examines the potential impact of existing case law on current legislative initiatives.

The objective of this study was to assess long-term sequelae of Salter-Harris type 2 injuries on growth of the distal femoral physis. A retrospective study of 20 patients with Salter-Harris type 2 distal femoral injuries, who were managed between 1994 and 2003, was carried out. The average period of follow-up was 4 years and 2 months. Mean age of fracture was 11 years (range 8-15 years). We classified radiologically these fractures into three types according to initial displacement on anteroposterior and lateral radiographs (type 1=less than 2 mm; type 2=more than 2 mm, contact between fragments; type 3=no contact). Further subdivision into A and B was made according to the absence or presence of metaphyseal comminution. Clinical and radiological outcomes were evaluated at latest follow-up. Two patients with type 1 injuries were treated conservatively, with no complication. All type 2 and 3 fractures (18) were reduced under general anesthesia. At latest follow-up, 14 patients (70%) sustained a complication due to either epiphysiodesis (12), femoral over-lengthening (1) or associated loss of knee motion (5). Seven out of the 12 epiphysiodeses were initial type B injuries. All type 3 fractures ended with complications. The prognosis of these fractures, often caused by a high-energy trauma, can be severe. Additional subdivision of Salter-Harris type 2 distal femoral physeal injuries is proposed to warn the clinician on specific fracture patterns with higher complication risk. Greater awareness of the numerous growth problems that may occur is needed in type 2B, in which the germinal layer of the physeal cells is damaged.

Spinal segmental dysgenesis is a complex closed dysraphism. The diagnostic criteria are: lumbar or thoracolumbar vertebral dysgenesis causing kyphosis, focal spinal cord narrowing without exiting roots, deformity of the lower limbs and paraplegia or paraparesis. We present a newborn who showed atypical features of bifocal spinal cord narrowing, without any vertebral abnormality at the proximal level. This seems to be a variant of this rare entity, whose early diagnosis is important, as surgical stabilisation of the spine is required.

The purpose of this study was to review the demographic data of children and adolescents with aneurysmal bone cysts (ABCs). The authors performed a retrospective, multicenter, pediatric population-based analysis of 156 patients with primary ABCs. Only patients with histologic confirmation of the diagnosis were included. A review of French and English literature of 255 children and adolescents was included regarding sex, location of the lesion and age at diagnosis. There were 212 boys and 199 girls with a median age at diagnosis of 10.2 years (range, 1.5-17 years). Forty-four patients were under 5 years of age; 111 patients were between 5 and 10 years of age, and 139 were older than 10 years of age. The femur, tibia, spine, humerus, pelvis and fibula were the most common locations. In 256 cases (62.7%), ABCs occurred in long bones. We also studied the data and location of 161 ABCs of the mobile spine (13 cases from our series and 148 from the literature review). There were 48 ABCs in the cervical spine, 48 in the thoracic spine, and 65 in the lumbar spine. We found no main differences in site distribution and sex, between the children and the general population.

Purpose: To report complications of direct fibrosing agent injection in the treatment of aneurysmal bone cysts (ABCs) in children., Materials and Methods: The authors retrospectively analyzed all cases of ABCs treated with direct fibrosing agent injection (Ethibloc; Ethnor Laboratories, Ethicon, Noderstedt, Germany) at Robert Debré Hospital since 1994. Histologic diagnosis was assigned by means of surgical biopsy findings prior to treatment. Treatment responses were categorized. Injection was administered with general anesthesia, computed tomographic guidance, and use of a 14- to 16-gauge needle. Contrast material was injected to determine presence of intracystic septa and verify absence of venous opacification. Amount of fibrosing agent injected corresponded to amount of contrast material necessary to fully opacify the cyst. Intraosseous needle track was obliterated with histoacryl injection., Results: Fifteen patients were treated. Mean follow-up was 80 months; no patient was lost to follow-up. One patient experienced pulmonary embolus that necessitated a 7-day intensive care unit stay. Four patients experienced early aseptic fistulization after the first injection, which led to surgical débridement and curettage. Five patients had transient inflammatory reaction with mild 38 degrees C fever, which was controlled with analgesic and antiinflammatory drugs. Eleven patients did not require surgery, and results at latest follow-up were considered to indicate complete healing (type 1 results) in nine and incomplete healing (type 2 results) in two. For type 1 results: Six patients received one injection, two received two injections, and one received three injections. For type 2 results: one patient received one injection, and one received three injections., Conclusion: A high rate of major local and general complications was encountered with use of direct fibrosing agent injection; the technique has been abandoned for treatment of ABCs., (Copyright RSNA, 2004)

Background: It has been reported that MRI using a dynamic gadolinium-enhanced subtraction technique can allow the early identification of ischaemia and the pattern of revascularisation in Legg-Calvé-Perthes (LCP) disease with increased spatial and contrast resolution. Therefore, dynamic gadolinium-enhanced subtraction (DGS) MRI may be a possible non-ionising substitute for bone scintigraphy., Objective: The purpose of this prospective study was to compare DGS MRI and bone scintigraphy in the assessment of femoral head perfusion in LCP disease., Materials and Methods: Twenty-six DGS MR images and bone scintigraphies of 25 hips in 23 children were obtained at different stages of LCP disease; three stage I, 12 stage II, six stage III and five stage IV (Waldenström classification). The extent of necrosis, epiphyseal revascularisation pathways (lateral pillar, medial pillar, and/or transphyseal perfusion) and metaphyseal changes were analysed., Results: Total agreement between both techniques was noted in the depiction of epiphyseal necrosis (kappa=1), and metaphyseal abnormalities (kappa=0.9). DGS MRI demonstrated better revascularisation in the lateral (kappa=0.62) and medial pillars (kappa=0.52). The presence of basal transphyseal reperfusion was more conspicuous with MRI., Conclusions: DGS MRI allows early detection of epiphyseal ischaemia and accurate analysis of the different revascularisation patterns. These changes are directly related to the prognosis of LCP disease and can aid therapeutic decision making.

Unlabelled: Idiopathic juvenile osteoporosis is a rare form of bone demineralization which occurs during childhood. The mechanism of disease remains unknown. We report a new case which illustrates the main difficulties of diagnosis and treatment., Case Report: A 7 year old girl was admitted because of painful disability of her lower limbs. Diagnosis was based on radiological signs, total bone density and bone histologic pattern. Plasma levels of calcium, phosphorus, alkaline phosphatases, 25-OH D3 and parathormone were within the normal range value. Other diseases associated with bone demineralization, such as enteric malabsorption, endocrine or tumoral diseases, were excluded. Recovery occurred after some months of treatment with calcium, vitamin D and rehabilitation, but we could not establish a clear causal relationship., Conclusion: The relative role of increased bone resorption or defective osteoblast function remain to be discussed. Recovery often occurs with or without treatment, but sequelae can lead to disability.

We treated 34 femoral shaft fractures in 32 children with elastic intramedullary nailing using titanium rods. The 24 boys and 8 girls ranged from 6-17 years. All fractures united. The weight bearing was authorized at an average of 67 days and was complete at an average of 89 days. All children returned to school before the end of the second postoperative month. An an average of 2.5 years, no rotational malalignment was present. Neither anteroposterior nor frontal malalignment of more than 2 degrees was noticed. A leg length discrepancy of more than 10 mm was present in 3 patients (8%). No injury of femoral head vascularization or of the proximal or distal growth plate was noticed. In our experience, this technique seems to be safe for the surgical treatment of the immature femoral shaft fractures. The elastic properties of titanium provide a very good stability of the montage, when the technique is correctly performed.

Purpose: To determine whether the simple technique of dynamic gadolinium-enhanced subtraction MR imaging, which is available on standard MR units, can detect ischemia of the femoral head in children with early Legg-Calvé-Perthes disease (LCP)., Materials and Methods: Bone perfusion of eight hips in four patients (mean age 7.5 years) was studied using dynamic gadolinium-enhanced subtraction MR imaging at the onset of proven LCP (with initial negative plain films). Enhancement of subtracted images was compared with that on standard MR images and with bone scintigraphy findings., Results: Subtraction MR imaging depicted ischemia as a widespread absence of enhancement and was in good agreement with bone scintigraphy. The subtraction technique improved the sensitivity and the specificity of MR imaging in two children. Furthermore, subtraction MR imaging allowed recognition of the pattern of early reperfusion., Conclusion: Our preliminary results indicate that dynamic gadolinium-enhanced subtraction MRI is a simple and promising means of early recognition of ischemia in LCP.

We reviewed 91 hips with slipped capital femoral epiphysis (SCFE) after an average follow-up period of 6 years 6 months. Different treatment methods used, according to types and stages of slipping, are discussed. In situ fixation appears to be the best procedure for SCFE with < 60% displacement. Careful reduction-fixation is indicated in acute and acute-on-chronic SCFE > 60%. Primary rotation osteotomies are associated with a high percentage of complications. Secondary osteotomies should be simple (preferably a subtrochanteric derotation osteotomy) to reduce the risk of necrosis. Preventive contralateral fixation is indicated when the growth cartilage is still open.

39 patients have been reoperated on for failed lumbar discs. In this series enhanced MRI, enhanced CT scan and disco-CT have been used. These modern imaging means allowed a better assessment for the causes of failure; thus, only in 4 patients was a pure periradicular fibrosis disclosed. The results of reoperations are significantly better than those of a previous series of the same institution, where these imaging devices could not been used. 76% of the patients benefited from reoperation.

Pure epiphysial detachment following injury to upper end of femur in two 2 year-old children was treated orthopedically by manual reduction under general anesthesia and plaster immobilization. Follow up radiographic and scintigraphic examinations showed favorable results with absence of necrosis after 10 and 17 months respectively. In contrast, long term surveillance will be necessary because of the rapid appearance of coxa magna.