Search

Introduction L’incidence de la scoliose idiopathique durant la marche chez les adolescents est encore trop peu decrite. L’evaluation de la deformation est essentiellement radiographique avec une modification de la posture naturelle due a l’examen. L’objectif de notre etude a ete de caracteriser l’incidence de la deformation rachidienne sur la posture naturelle en statique et en dynamique lors de la marche comparee a une population saine. Materiel et methodes Il s’agit d’une etude prospective entre 2013 et 2014 comparant une population de 26 adolescents porteurs de scoliose idiopathique severe (ASI) programmes pour arthrodese vertebrale avec un groupe de 12 sujets sains. Une analyse descriptive de cette population d’etude a ete realisee selon les parametres demographiques et anthropomorphiques. En phase dynamique, tous ont beneficie d’une analyse cinematique 3D (Vicon Optoelectronic System, Oxford, Royaume-Uni) et une plateforme de forces (AMTI, Etats-Unis). Un modele cinematique de 34 marqueurs provenant d’une combinaison du modele Rachis Timone (MRT) pour la partie superieure du corps, associe a celui d’Helen Hayes pour les membres inferieurs, a ete utilise. Quatre descripteurs statiques de la position debout a l’arret (coronal vertical axis [CVA] sagittal vertical axis [SVA] version pelvienne) et sept dynamiques (angle pelvis-acromion [APA] – rotation du bassin – rotation des hanches – flexion des genoux – flexion des chevilles – inversion eversion des chevilles – foot progression angle [FPA]) ont ete decrits permettant l’analyse des trois segments porteurs. Resultats Les parametres significatifs des trois elements etudies ont ete l’APA et le SVA pour le tronc ; la rotation pelvienne et de la hanche pour le bassin ; le FPA, la flexion des genoux et l’angle de flexion dorso-plantaire pour les membres inferieurs. Les patients scoliotiques presentent une modification significative de l’axe de rotation, de l’obliquite et de l’incidence pelvienne. Discussion Notre etude montre que la combinaison de donnees dynamiques par le biais de l’analyse quantitative de la marche permet l’elaboration de mesures exploitables en clinique courante. Ceci permet d’identifier et de quantifier l’influence de la scoliose idiopathique dans les trois plans de l’espace sur le tronc, le bassin et les membres inferieurs en posture naturelle. Notre etude montre que la deformation scoliotique s’exprime en situation ecologique essentiellement dans le plan transversal. L’evaluation dynamique en 3D est un nouvel outil d’evaluation des resultats permettant d’apprecier l’efficacite de la prise en charge therapeutique en clinique courante. L’etape suivante sera d’explorer s’il existe une signature reperable lors de la marche pour differents types de deformations scoliotiques ?

Introduction. While thoracolumbar fractures are common lesions, no strong consensus is available at the moment.Objectives. The aim of this study was to evaluate the results of a minimal invasive strategy using percutaneous instrumentation and anterior approach in the management of thoracolumbar unstable fractures.Methods. 39 patients were included in this retrospective study. Radiologic evaluation was based on vertebral and regional kyphosis, vertebral body height restoration, and fusion rate. Clinical evaluation was based on Visual Analogic Score (VAS). All evaluations were done preoperatively and at 1-year follow-up.Results. Both vertebral and regional kyphoses were significantly improved on postoperative evaluation (13° and 7° versus −1° and −9° P<0.05, resp.) as well as vertebral body height (0.92 versus 1.16,P<0.05). At 1-year follow-up, mean loss of correction was 1°. A solid fusion was visible in all the cases, and mean VAS was significantly reduced form 8/10 preoperatively to 1/10 at the last follow-up.Conclusion. Management of thoracolumbar fractures using percutaneous osteosynthesis and minimal invasive anterior approach (telescopic vertebral body prosthesis) is a valuable strategy. Results of this strategy offer satisfactory and stable results in time.

Introduction Les fractures supracondyliennes (FSC) du coude de l’enfant sont les fractures du coude les plus frequentes. Cependant, les modalites d’osteosynthese restent controversees. L’objectif de cette etude etait de comparer les resultats de 5 types d’osteosynthese dans le traitement des FSC de l’enfant. Materiel et methodes De 2006 a 2016, les dossiers de patients pediatriques admis dans notre institution pour FSC stade 3–4 (Lagrange-Rigault) ont ete revus. Differents parametres radiocliniques ont ete collectes en postoperatoire et au dernier recul, comme l’angle de Baumann, l’anteversion de la palette humerale et le temps operatoire. Un defaut de reduction etait considere lorsqu’il existait un deficit de l’angle de Baumann ou de l’anteversion de plus de 15° ou un trouble de rotation. Les resultats etaient analyses en fonction du type d’osteosynthese realisee. Resultats Sur une periode de 10 ans, 251 patients ont ete inclus (âge : 6,4 ans, recul : 4,7 mois). Les differents types d’osteosynthese etaient : ECMES (n = 16), 2 broches en croix (n = 33), 2 broches laterales et 1 mediale (n = 144), 2 broches laterales (n = 33) et 3 broches laterales (n = 25). Un mini-abord (2 cm) etait realise pour l’insertion de la broche mediale. La frequence des defauts de reduction ne variait pas en fonction de l’osteosynthese. Les patients osteosyntheses par 2 broches laterales avaient un temps operatoire plus court (33 min, p = 0,046). Les patients ayant eu un ECMES avaient un delai d’ablation du materiel plus long (54j, p = 0,03). L’insertion d’une broche mediale etait associee a un taux de deplacement secondaire plus faible (2 vs. 8,6 %, p = 0,04) avec un taux de complication neurologique identique (3,4 vs. 3,4 %, p = 0,98). Discussion Cette etude est l’une des plus importantes rapportant les resultats du traitement des FSC selon differentes osteosyntheses sous la forme d’une etude de cohorte retrospective. Les resultats demontrent que l’ajout d’une broche mediale, bien que rallongeant le temps operatoire, permette de limiter les deplacements secondaires. La realisation d’un mini-abord medial permet de reduire le taux de lesions neurologiques iatrogenes. Conclusion L’ajout d’une broche mediale permet une meilleure stabilisation du foyer de fracture sans augmentation du risque de lesion neurologique iatrogene et devrait etre considere lors du traitement chirurgical des FSC de l’enfant.

Introduction La restauration de l’alignement sagittal regional est complexe, notamment lors de la realisation de fusions courtes dans le traitement des scolioses lombaires. A ce jour, il n’existe pas de preuves de la relation entre l’anatomie pelvienne, l’alignement global et la lordose lombaire segmentaire. L’objectif de notre etude etait de demontrer qu’il existait une influence de la morphologie pelvienne et de l’equilibre sagittal sur la repartition de la lordose lombaire. Materiel et methodes Des sujets asymptomatiques ont ete inclus et stratifies par incidence pelvienne (IP) ( 60˚). La lordose segmentaire (lordose entre 2 vertebres adjacentes) et la lordose cumulative (lordose entre une vertebre donnee et S1) etaient mesurees. Pour ces 2 parametres, des correlations avec les parametres sagittaux etaient effectuees, comme l’adequation entre la lordose lombaire et l’incidence pelvienne (IP-LL). Resultats Au total, 119 sujets asymptomatiques ont ete inclus dans l’etude. La stratification par IP montrait des differences dans la lordose segmentaire entre L1 et L4, entrainant des modifications de la lordose cumulative au-dessus de L3. Il existait une correlation significative entre la lordose proximale et l’IP (de T12L1 a L3L4, p p Discussion Cette etude a permis de mettre en evidence les relations entre l’alignement global, la morphologie pelvienne et la repartition de la lordose lombaire en s’appuyant sur l’analyse d’une cohorte de sujets sains. Contrairement a ce qui est couramment decrit dans la litterature, les resultats suggerent que la portion proximale de la lordose lombaire soit sous l’influence de l’incidence pelvienne alors que la portion distale est un reflet de l’alignement sagittal global. Conclusion L’alignement sagittal global et la morphologie pelvienne influencent la lordose lombaire a differents niveaux. Ce resultat devrait etre pris en compte dans la planification preoperatoire, notamment lors de la fusion d’une portion de la lordose lombaire.

Introduction L’utilisation de substituts osseux dans le traitement des scolioses idiopathiques de l’adolescent (SIA) est recommandee pour eviter les pseudarthroses. Le taux de pseudarthrose avec les instrumentations modernes plus rigides a ete rapporte comme moins important, meme sans utilisation de substitut osseux. L’objectif de cette etude etait de determiner l’interet des substituts osseux sur le taux de fusion chez les patients traites par arthrodese posterieure avec une instrumentation moins rigide (bandes sous-lamaires) pour SIA. Materiel et methodes Des patients programmes pour arthrodese posterieure avec bandes sous-lamaires pour le traitement d’une SIA ont ete prospectivement inclus dans cette etude. Ces patients etaient operes sans apport de substitut osseux (groupe sans substitut). Des donnees cliniques et radiographiques ont ete collectees jusqu’a un minimum de 2 ans de recul. Une pseudarthrose etait diagnostiquee si au moins un des elements suivants etait present : persistance de douleurs, bris du materiel ou perte de correction de plus de 10° au dernier recul. Les resultats ont ete compares a un group temoin apparie pour l’âge et le sexe (1:1) chez qui la meme technique chirurgicale etait employee mais avec apport de substitut osseux (beta-calcium triphosphate). Resultats Au total, 88 patients ont ete inclus, d’âge moyen 14,8 ans. Le recul moyen etait de 30,9 mois. Dans le groupe « sans substitut » (n = 44), l’angle de Cobb preoperatoire moyen etait de 56° contre 20° en postoperatoire et 22° au dernier recul. Les parametres radiographiques etaient les memes dans les 2 groupes aux differents reculs. Le taux de fusion etait le meme dans les 2 groupes (97,7 % vs 95,5 %, p = 0,56). Au dernier recul, 1 pseudarthrose etait diagnostiquee dans le groupe « sans substituts » contre 2 dans le groupe temoin. Discussion Cette etude est la premiere a rapporter le taux de fusion avec l’utilisation de bandes sous-lamaires dans le traitement par arthrodese posterieure des SIA. Malgre l’utilisation d’une instrumentation moins rigide, le taux de fusion sans apport de substitut osseux etait de 97,7 %. Ces resultats suggerent que l’apport de materiel additionnel ne soit pas utile pour l’obtention d’une arthrodese solide chez ces jeunes patients a fort potentiel de consolidation. Conclusion Malgre l’utilisation d’un materiel moins rigide, l’apport de substitut osseux n’est pas obligatoire lors de la realisation d’une arthrodese par voie posterieure a l’aide de bandes sous-lamaires.

Introduction Les fractures supracondyliennes du coude (FSC) sont courantes en traumatologie pediatrique. L’experience est un facteur rarement considere alors que ces patients sont souvent operes par de jeunes chirurgiens. L’objectif etait de comparer les resultats du traitement chirurgical des FSC pediatriques en fonction de l’experience du chirurgien. Materiel et methodes Tous les patients ayant une FSC stade 3–4 (Lagrange et Rigault) pour lesquels les donnees etaient disponibles ont ete inclus. Differents parametres radiocliniques etaient recueillis en postoperatoire et au dernier recul. Un defaut de reduction etait considere lorsqu’il existait un deficit de l’angle de Baumann ou de l’anteversion de plus de 15° ou un trouble de rotation. Une analyse en fonction de l’experience du chirurgien (plus ou moins d’un an) et du volume (nombre de patients par an) a ete realisee. Resultats Les donnees etaient disponibles pour 236 patients (âge : 6,4 ans, recul : 5 mois). Les patients operes par un chirurgien plus jeune (n = 69) avaient un temps operatoire et un delai d’AMOS plus longs (respectivement 61 vs. 41 min et 48 vs. 40 jours, p Discussion Cette etude est la premiere a rapporter l’impact de l’experience sur les resultats du traitement des FSC sous la forme d’une etude de cohorte retrospective. Les resultats suggerent que l’experience chirurgicale est primordiale. Elle permet de diminuer la. Conclusion L’experience et le volume de patients operes par an sont 2 parametres essentiels influencant la qualite de la prise en charge chirurgicale. Ces parametres devraient etre pris en compte, notamment, lors de la prise de decision d’operer ces patients en dehors des heures ouvrees.

Management of high-grade spondylolisthesis is challenging and to date no therapeutic consensus is available. Various surgical procedures have been described using unique or double approach. The aim of the study is to describe an original technique using a posterior-only approach to achieve a circumferential lumbosacral fusion with a custom-made screw. In our experience, eight patients (mean age 15 years old) were treated for grade III or IV slipping without instrumental reduction. Surgical technique included a laminectomy from L5 to S2, then after mobilization of neural elements a guide wire was inserted from the posterior side of S2 to the antero-superior corner of L5. A specific drill was used and the 10-mm screw was then inserted under fluoroscopic guidance. Further steps included a discectomy, lumbosacral interbody graft and posterolateral graft to obtain a circumferential fusion. Clinical and radiological evaluations were obtained. On the whole series, solid fusion was achieved after 6 months on average. Sagittal realignment was observed with a regression of pelvic retroversion and hip flessum, a lumbarization of the lumbar lordosis and an improvement of the thoracic kyphosis. For one patient, a postoperative S1 deficit was observed. This technique provides satisfactory results in the management of high-grade spondylolisthesis. This concept is based on a double spine instability considering viscoelastic properties of the disc and postoperative sagittal reciprocal changes as prerequisite. This posterior-only approach represents a valuable alternative to other procedures.

Introduction En cas d’une lesion envahissant l’epiphyse et le cartilage de croissance la resection devra etre metaphyso epiphysaire avec une arthrectomie monobloc, la reconstruction se fait alors a l’aide d’une prothese massive. En cas d’une lesion uniquement metaphysaire, la resection permet une conservation de l’articulation du genou et une reconstruction dite biologique par perone vascularise et lame plaque. Le but de ce travail est d’evaluer par analyse quantifiee de la marche la cinetique et la cinematique de ces patients en postoperatoire. Patients et methode Il s’agit d’une etude retrospective incluant 15 patients operes dans un meme centre pediatrique. Tous les patients ont beneficie d’une analyse quantifiee de la marche en postoperatoire permettant d’obtenir des donnees cinematique et cinetique. Le groupe prothese comprenait 6 patients et le groupe reconstruction biologique 9 patients. Nous avons compare ces resultats a un groupe de sujets sains. Resultats Parametres spatio-temporels - la vitesse de marche etait statistiquement diminuee ( p p Discussion le pattern de marche jambe raide est retrouve dans la litterature, neanmoins il n’existe pas d’etudes concernant les reconstructions biologiques. Conclusion Ces 2 techniques chirurgicales permettent une marche efficace avec des mecanismes de compensation differents. Les patients presentent une marche genou raide pour stabiliser leur genou ce qui entraine un defaut d’amortissement et de propulsion. Les patients du groupe prothese utilisent les proprietes mecaniques de leur prothese pour verrouiller leur genou – mise en hyper-extension.

Introduction Parmi les nombreuses modifications anatomiques et posturales se produisant dans l’enfance, l’adaptation du rachis semble etre essentielle dans l’acquisition de la bipedie. Le but de notre etude etait de decrire l’evolution de l’equilibre rachidien lors de l’acquisition de la marche pendant l’enfance a l’aide des outils d’analyse du mouvement. Patients et methode Trente-six enfants sains âges de 3 a 16 ans ont ete inclus dans cette etude. L’analyse du mouvement etait effectuee sur un essai de marche de 9 m. Differents parametres cinematiques etaient enregistres et analyses comme l’angle thoracique (AT), l’angle lombaire (AL) et le sagittal vertical axis (SVA). Les parametres cinetiques etudies etaient les moments (Nm kg) aux charnieres thoracolombaire et lombosacree. Resultats L’AT et l’AL n’etaient pas statistiquement correles a l’âge ( p = 0,32 et p = 0,41). Le SVA augmentait significativement avec l’âge ( p p = 0,003), signifiant que les contraintes mecaniques dans le plan sagittal augmentaient avec l’âge. Il existait une correlation negative significative entre les moments de torsion aux charnieres thoracolombaire et lombosacree et l’âge ( p = 0,0002 et p = 0,0006), signifiant que les contraintes mecaniques dans le plan transversal aux charnieres thoracolombaire et lombosacree diminuent avec l’âge. Discussion Peu d’auteurs ont etudie l’evolution dynamique du rachis pendant la croissance en analyse du mouvement. Ces resultats montrent que l’acquisition des courbures rachidiennes est une caracteristique morphologique tres precoce, apparaissant avant l’âge de 3 ans. L’analyse cinetique montre qu’avec l’âge, il existe une diminution des contraintes en torsion alors que les contrainte dans le plan sagittal augmentent. Ces changements de la biomecanique rachidienne s’expliquent par le role majeur du tronc dans l’acquisition de la bipedie, permettant la stabilisation de la posture malgre l’immaturite des membres inferieurs. Secondairement, ces contraintes vont changer et s’appliquer dans le plan sagittal.

Introduction. Management of elderly patients with thoracolumbar fractures is still challenging due to frequent osteoporosis and risk of screws pull-out. The aim of this study was to evaluate results of a percutaneous-only procedure to treat these fragile patients using cement-augmented screws.Methods. 12 patients diagnosed with a thoracolumbar fracture associated with an important loss of bone stock were included in this prospective study. Surgical procedure included systematically a percutaneous osteosynthesis using cemented fenestrated screws. When necessary, additional anterior support was performed using a kyphoplasty procedure. Clinical and radiographic evaluations were performed using CT scan.Results. On the whole series, 15 fractures were diagnosed and 96 cemented screws were inserted. The difference between the pre- and postoperative vertebral kyphosis was statistically significant (12.9° versus 4.4°,P=0.0006). No extrapedicular screw was reported and one patient was diagnosed with a cement-related pulmonary embolism. During follow-up period, no infectious complications, implant failures, or pull-out screws were noticed.Discussion. Aging spine is becoming an increasing public health issue. Management of these patients requires specific attention due to the augmented risk of complications. Using percutaneous-only screws fixation with cemented screw provides satisfactory results. A rigorous technique is mandatory in order to achieve best outcomes.

We report the case of a patient diagnosed with a pathological fracture of the odontoid dens related to a renal carcinoma metastasis and treated by an original technique. In order to achieve correct stabilization of the fracture and to preserve rotational neck mobility, an anterior approach combining an odontoid screw fixation and a balloon kyphoplasty was performed. This minimal invasive strategy provided satisfactory clinical and radiological results for this unstable lesion. To our knowledge, this technique has not been previously reported and could be a valuable alternative approach in the management of craniocervical metastatic lesions for these fragile patients.

Background Global sagittal malalignment is significantly correlated with health-related quality-of-life scores in the setting of spinal deformity. In order to address rigid deformity patterns, the use of spinal osteotomies has seen a substantial increase. Unfortunately, variations of established techniques and hybrid combinations of osteotomies have made comparisons of outcomes difficult. Objective To propose a classification system of anatomically-based spinal osteotomies and provide a common language among spine specialists. Methods The proposed classification system is based on 6 anatomic grades of resection (1 through 6) corresponding to the extent of bone resection and increasing degree of destabilizing potential. In addition, a surgical approach modifier is added (posterior approach or combined anterior and posterior approaches). Reliability of the classification system was evaluated by an analysis of 16 clinical cases, rated 2 times by 8 different readers, and calculation of Fleiss kappa coefficients. Results Intraobserver reliability was classified as "almost perfect"; Fleiss kappa coefficient averaged 0.96 (range, 0.92-1.0) for resection type and 0.90 (0.71-1.0) for the approach modifier. Results from the interobserver reliability for the classification were 0.96 for resection type and 0.88 for the approach modifier. Conclusion This proposed anatomically based classification system provides a consistent description of the various osteotomies performed in spinal deformity correction surgery. The reliability study confirmed that the classification is simple and consistent. Further development of its use will provide a common frame for osteotomy assessment and permit comparative analysis of different treatments.

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

Multicenter, retrospective radiographic analysis.To evaluate the impact that preoperative spinopelvic parameters have on postoperative sagittal vertical axis (SVA). The researchers hypothesized that patients with a large preoperative pelvic tilt (PT) would require more extensive lumbar pedicle subtraction osteotomy (LPSO) procedures to reestablish anatomic postoperative SVA than patients with normal preoperative PT.Restoration of anatomic sagittal spinal alignment has been demonstrated to improve clinical outcomes. However, the degree to which spinopelvic parameters contribute to sagittal spinal malalignment is poorly understood.Multicenter, retrospective analysis of 183 consecutively enrolled adult spinal deformity patients treated with LPSO procedures for correction of sagittal malalignment. Preoperative and postoperative freestanding full-length sagittal X-rays were analyzed for regional curves, pelvic parameters, and global alignment. Only patients with a preoperative SVA greater than 10 cm and a postoperative SVA less than 5 cm were retained for analysis. Patients were divided into 2 groups according to preoperative PT (low PT, less than 30°; and high PT, ≥30°). Independent t test analysis was used to determine differences in correction required to achieve postoperative SVA less than 5 cm.A total of 55 patients were identified for analysis. Low PT (n = 30) had lower preoperative PT than high PT (n = 25; 25° vs. 42°, respectively; p.001). Analysis of the osteotomy performed demonstrated that the high PT group required a larger osteotomy resection (30° vs. 23°; p = .039) and a larger correction of lumbar lordosis (-43° vs. -31°; p = .006) to achieve an acceptable postoperative SVA (less than 5 cm).This study demonstrates that patients with high PT in conjunction with sagittal spinal malalignment require larger lumbar osteotomy procedures, including a greater osteotomy resection and larger lumbar lordosis correction, to obtain a satisfactory postoperative SVA. Surgeons performing LPSO procedures must evaluate preoperative spinopelvic parameters, including PT, to avoid undercorrection and residual deformity after complex sagittal realignment procedures.

This paper is a narrative review of normal cervical alignment, methods for quantifying alignment, and how alignment is associated with cervical deformity, myelopathy, and adjacent-segment disease (ASD), with discussions of health-related quality of life (HRQOL). Popular methods currently used to quantify cervical alignment are discussed including cervical lordosis, sagittal vertical axis, and horizontal gaze with the chin-brow to vertical angle. Cervical deformity is examined in detail as deformities localized to the cervical spine affect, and are affected by, other parameters of the spine in preserving global sagittal alignment. An evolving trend is defining cervical sagittal alignment. Evidence from a few recent studies suggests correlations between radiographic parameters in the cervical spine and HRQOL. Analysis of the cervical regional alignment with respect to overall spinal pelvic alignment is critical. The article details mechanisms by which cervical kyphotic deformity potentially leads to ASD and discusses previous studies that suggest how postoperative sagittal malalignment may promote ASD. Further clinical studies are needed to explore the relationship of cervical malalignment and the development of ASD. Sagittal alignment of the cervical spine may play a substantial role in the development of cervical myelopathy as cervical deformity can lead to spinal cord compression and cord tension. Surgical correction of cervical myelopathy should always take into consideration cervical sagittal alignment, as decompression alone may not decrease cord tension induced by kyphosis. Awareness of the development of postlaminectomy kyphosis is critical as it relates to cervical myelopathy. The future direction of cervical deformity correction should include a comprehensive approach in assessing global cervicalpelvic relationships. Just as understanding pelvic incidence as it relates to lumbar lordosis was crucial in building our knowledge of thoracolumbar deformities, T-1 incidence and cervical sagittal balance can further our understanding of cervical deformities. Other important parameters that account for the cervical-pelvic relationship are surveyed in detail, and it is recognized that all such parameters need to be validated in studies that correlate HRQOL outcomes following cervical deformity correction.

STUDY DESIGN Multicenter, retrospective analysis of 183 consecutive patients undergoing lumbar osteotomy. OBJECTIVE To evaluate cause and impact of posterior postoperative alignment. SUMMARY OF BACKGROUND DATA Sagittal malalignment in the setting of adult spinal deformity (ASD) has shown significant correlation with pain and disability. Surgical treatment often entails correction of deformity by pedicle subtraction osteotomies (PSO). Key radiographical spinopelvic objectives to reach improvement in clinical outcomes have been previously reported. Although anterior alignment is a cause of poor outcomes, the impact and cause of posterior spinal alignment by PSO has not been reported. METHODS The patient inclusion criteria were age, more than 18 years, with a diagnosis of sagittal plane deformity (C7 plumbline offset >5 cm, a pelvic tilt >20°, or a lumbar lordosis to pelvic incidence mismatch of ≥10°) requiring a surgical procedure involving a lumbar posterior osteotomy and a long fusion. Patients were divided into 3 groups based on postoperative sagittal vertical axis (SVA): neutral alignment (0 50 mm), and posterior alignment (SVA < 0 mm). All patients underwent pre- and postoperative full-length sagittal spine radiography. Differences between groups were evaluated using ANOVA and χ² analysis. RESULTS Seventy-six patients were postoperatively classified in the anterior group: 59 in the neutral group and 48 in the posterior group. These groups were comparable preoperatively in terms of surgical status (revision vs. primary surgery) and regional alignment (lumbar lordosis and thoracic kyphosis). The patients with posterior alignment were younger and had a significantly lower pelvic incidence (53° vs. 62°), preoperative pelvic tilt (30 vs. 36°), SVA (94 vs. 185 mm) and cervical lordosis (16° vs. 25°) than patients in the anterior alignment group. No significant differences were found in terms surgical procedure. Patients in the posterior alignment group demonstrated a significantly greater change in SVA and pelvic tilt correction (P < 0.05) but with a lower gain in thoracic kyphosis (5 vs. 12°) and reduction of cervical lordosis (4° vs. 22°). CONCLUSION A significantly lower pelvic incidence and lack of restoration of thoracic kyphosis may lead to sagittal overcorrection with a posterior alignment. Although the clinical significance of posterior malalignment is still unclear, this study showed a compensatory loss of cervical lordosis in these patients. Particular attention must be paid to preoperative planning before sagittal realignment procedures. Further study will be necessary to evaluate long-term clinical outcomes of these patients.

Introduction La standardisation de la prise en charge initiale des fractures du bassin dans des centres specialises a permis de limiter la mortalite liee a ces traumatismes graves. Cependant, le retentissement fonctionnel de ces fractures reste une preoccupation majeure. L’objectif de cette etude etait d’evaluer les resultats fonctionnels apres fracture extracotyloidienne du bassin en fonction du type de traitement choisi osteosynthese ou traitement orthopedique. Materiel et methodes Pour cette etude retrospective monocentrique, nous avons inclus l’ensemble des patients admis pour fracture du bassin sans atteinte cotyloidienne suite a un traumatisme a haute energie entre le 1er janvier 2008 et le 31 juillet 2015. Etaient exclus les patients vivant a l’etranger ou les patients decedes des suites de l’accident. Le recul minimum etait de 9 mois. Trois scores fonctionnels ont ete utilises : Majeed, OMS et SF-12 version 2. L’existence d’une inegalite de longueur des membres ressentie, de lombalgies, de sequelles urogenitales ou neurologiques a ete enregistree. Par ailleurs, la qualite de la reduction etait analysee afin de mettre en evidence une correlation entre defaut de reduction et alteration des scores fonctionnels. Resultats Parmi les 146 patients inclus, 91 ont pu etre evalues. Le recul moyen etait de 53 mois (9–99). La fracture du bassin avait ete osteosynthesee chez 37 patients et traitee orthopediquement dans 54 cas. Le score de Majeed moyen etait de 77/100 pour les patients operes contre 86 pour les non operes (p = 0,008). On ne retrouvait pas de difference significative entre les deux groupes concernant le score OMS et SF12. Discussion L’obtention d’une reduction parfaite d’une fracture du bassin, si necessaire chirurgicale, est correlee a une meilleure fonction. Le traitement orthopedique devrait etre reserve aux fractures non deplacees ou aux patients a mauvais pronostic fonctionnel.

Object Sagittal spinopelvic malalignment is a significant cause of pain and disability in patients with adult spinal deformity. Surgical correction of spinopelvic malalignment can result in compensatory changes in spinal alignment outside of the fused spinal segments. These compensatory changes, termed reciprocal changes, have been defined for thoracic and lumbar regions but not for the cervical spine. The object of this study was to evaluate postoperative reciprocal changes within the cervical spine following lumbar pedicle subtraction osteotomy (PSO). Methods This was a multicenter retrospective radiographic analysis of patients from International Spine Study Group centers. Inclusion criteria were as follows: adults (>18 years old) with spinal deformity treated using lumbar PSO, a preoperative C7–S1 plumb line greater than 5 cm, and availability of pre- and postoperative full-length standing radiographs. Results Seventy-five patients (60 women, mean age 59 years) were included. The lumbar PSO significantly improved sagittal alignment, including the C7–S1 plumb line, C7–T12 inclination, and pelvic tilt (p 2 = 0.53, p Conclusions Adults with positive sagittal spinopelvic malalignment compensate with abnormally increased cervical lordosis in an effort to maintain horizontal gaze. Surgical correction of sagittal malalignment results in improvement of the abnormal cervical hyperlordosis through reciprocal changes.

Evaluation of spinal posture has recently benefited from the contribution of three dimensional reconstruction technologies that have helped improve our understanding of this dynamic balance. The aim of this study was to present the preliminary results of a three dimensional protocol to analyze postural balance. This analytical method is not limited by certain constraints of the radiological approach and evaluates postural balance using a new approach taking into account the net efforts of different inter segmental centers. These preliminary results show the technical feasibility of the protocol. Its future development and clinical use could provide a better understanding of postural balance disorders, and help evaluate the impact of surgical correction on spinal balance. Postural balance; Spine; Intersegmental moments; Biomechanics

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

Pelvic tilt is an established measure of position which has been tied to sagittal plane spinal deformity. Increased tilt is noted in the setting of the aging spine and sagittal malalignment syndromes such as flatback (compensatory mechanism). However, the femoral heads are often poorly visualized on sagittal films of scoliosis series in adults, limiting the ability to determine pelvic incidence and tilt. There is a need to establish a coronal plane (better visualization) pelvic parameter which correlates closely with pelvic tilt. This is a retrospective review of 71 adult patients (47 females and 24 males) with full-length standing spine radiographs. Visualization of all spinal and pelvic landmarks was available coronally and sagittally (including pelvis and acetabuli). Pelvic tilt was calculated through validated digital analysis software (SpineView®). A new parameter, the sacro-femoral-pubic angle (midpoint of S1 endplate to centroid of acetabuli to superior border of the pubic symphysis) was analyzed for correlation (and predictive ability) with sagittal pelvic tilt. The sacro-femoral-pubic angle (SFP angle) was highly correlated to PT, and according to this analysis, pelvic tilt could be estimated by the formula: PT = 75 − (SFP angle). A Pearson’s correlation coefficient of 0.74 (p

Epub; Multiple hereditary exostoses are frequently observed in children, but vascular complications from exostoses in siblings are rare. We report the case of a 10-year-old boy, admitted for dyspnea and chest pain related to a hemothorax due to a right eighth rib exostosis. He was successfully treated by costal resection and chest tube drainage. In retracing his family history, another vascular involvement was discovered. His sister had presented a few years earlier with a spontaneous rupture of brachial artery with radial nerve palsy. To date, only a few cases of spontaneaous hemothorax related to a thoracic exostosis have been described, and to our knowledge, a family association of vascular lesions has not been reported yet. Patients with multiple hereditary exostoses require clinical and radiographic follow-ups during growing years. The main problem is determining the best way to identify dangerous exostoses that may cause vascular lesions. In association with standard surveillance of patients with multiple hereditary exostoses, we suggest performing specific examinations in cases of known thoracic lesions and for patients with a family history of vascular impingement.

New methods of spinal percutaneous fixation are developing very rapidly. However, few studies to date have focused on long-segment methods of instrumentation.To report the technical feasibility of long-segment percutaneous stabilization for various indications.The study included 24 patients with a mean age of 58 years (range 38-79). The etiologies included trauma, infection, tumors, or pathology secondary to degenerative lumbar scoliosis. The damaged vertebrae ranged from T5 to L4. All of the patients underwent posterior percutaneous long-segment fixation. When necessary, the anterior spinal column was stabilized by balloon kyphoplasty or via anterior approach. The results obtained were analyzed on the basis of clinical and radiological criteria.The constructs involved four levels on average per patient, located between T3 and S1. No extra-pedicular misplacements were observed. Two technical difficulties were noticed without clinical consequences. A significant improvement in the pain levels was obtained in all the patients in this series.Long-segment percutaneous fixation was found to be technically feasible and to considerably improve the patients' spinal deformations. When associated with balloon kyphoplasty, this intervention seems to provide less loss of correction than previous methods, and posterior fusion was therefore not required. As with all new methods, there is a learning curve, and the indications have to be strictly observed. Further studies need to be performed, however, with a longer follow-up to confirm the absence of long-term complications.

STUDY DESIGN: A case of a 3-part fracture of the axis combining an odontoid dens and a hangman fracture is reported. OBJECTIVE: To describe a single anterior procedure allowing stabilization with an odontoid screw fixation and a C2-C3 fusion in a case of complex fracture of the axis. SUMMARY OF BACKGROUND DATA: Even if fractures of the axis are common, multiples fractures of the axis are rare and their management is still challenging for surgeons who have to achieve primary stability, early mobilization, preserved cervical range of motion, and favorable outcome. METHODS: A 79-year-old man was referred in our neurosurgical department 3 weeks after a bicycle accident. He had persistent neck pain without radicular pain. Neurologic examination was normal. The initial CT scan showed a rare and complex fracture of the axis consisting of a fracture of the dens and a traumatic spondylolisthesis of C2-C3. RESULTS: The surgical procedure was performed using an anterior cervical approach under fluoroscopic guidance. First, a C2-C3 fusion was performed using an iliac crest graft. Then an anterior odontoid screw was placed under fluoroscopic guidance. Finally, an anterior plating of C2-C3 covering the odontoid screw was achieved. Postoperative course was uneventful and patient was discharged at day 6. CONCLUSION: This single time procedure was able to achieve primary stability of the fractures of the axis and offers the possibility of an early mobilization of the patient with a good outcome. This approach allowed a better preservation of the cervical range of motion compared with a classic posterior fusion. Language: en

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

Introduction Les spondylodiscites restent des pathologies graves pouvant entrainer une impotence fonctionnelle et une destruction vertebrale. Une prise en charge mini-invasive par osteosynthese percutanee associe a une discectomie ou corporectomie pourrait ameliorer les suites operatoires de ces patients fragiles. Patients et methode Entre 2008 et 2015, 28 cas de spondylodiscite (20 hommes et 8 femmes, âge moyen 60 ans) sans deficit neurologique ont ete inclus dans ce travail. Le niveau concerne etait lombaire (78 %) au niveau de la charniere thoracolombaire (7 %) ou thoracique (14 %). La technique chirurgicale comportait systematiquement une osteosynthese percutanee associee a une discectomie (86 %) ou une corporectomie (14 %) par une voie anterieure associee. La reconstruction anterieure utilisait une cage avec de la BMP2 (19 %), un greffon osseux (77 %), ou un corps prothetique expansible (4 %). Resultats L’EVA moyenne preoperatoire etait de 9 10 avec une evolution moyenne des symptomes de 3 mois. La realisation de l’osteosynthese percutanee etait toujours possible dans un premier temps et les 2 temps chirurgicaux etaient realises conjointement dans 63 % des cas. Un lever precoce etait possible dans 80 % des cas a j3 avec une duree moyenne d’hospitalisation de 10 jours [4–29]. Lors de la sortie l’EVA moyenne etait de 4 10. La realisation de prelevements bacteriologiques permettait une identification du germe dans 67 % des cas (76 % dans le groupe vierge d’antibiotherapie preoperatoire) avant instauration d’une antibiotherapie postoperatoire au long cours (3 mois). Dans les suites operatoires, aucune aggravation neurologique n’etait notee, un patient presentait une infection superficielle de cicatrice traitee medicalement et un patient etait repris pour une fracture sus-jacente a l’osteosynthese. Au recul de 3 mois postoperatoires (2 perdus de vue), aucun cas de debricolage n’etait rapporte et le traitement antibiotique etait systematiquement arrete devant la bonne evolution. Le taux de fusion intervertebrale etait de 100 % chez les patients revus a 1 an (53 % des patients). Discussion La prise en charge chirurgicale des spondylodiscites est indiquee en cas de douleurs invalidantes ou de destruction vertebrale. L’association d’une osteosynthese percutanee et discectomie corporectomie par voie anterieure permet une diminution rapide et significative des douleurs ainsi qu’une remise en charge precoce. La morbidite operatoire et perioperatoire est faible avec une guerison systematique de l’infection dans cette serie, associee a un taux de fusion satisfaisant. Chez ces patients fragiles, la realisation d’une strategie mini-invasive constitue donc une alternative interessante.

AIM: To describe initial results and experimental error measurement of a protocol analyzing Human posture through sagittal intersegmental moments. METHODS: Postural analysis has been recently improved by development of three-dimensional radiographic imaging systems. However, in various situations such as global sagittal anterior malalignment interpretation of radiographs may not represent the real alignment of the subject. The aim of this study was to present initial results of a 3D biomechanical protocol. This protocol is obtained in a free standing position and characterizes postural balance by measurement of sagittal intersegmental net moments. After elaboration of a specific marker-set, 4 successive recordings were done on two volunteers by three different operators during three sessions in order to evaluate the experimental error measurement. A supplementary acquisition in a “radiographic” posture was also obtained. Once the data acquired, joint center, length, anatomical frame and the center of mass of each body segment was calculated and a mass affected. Sagittal net intersegmental moments were computed in an ascending manner from ground reaction forces at the ankles, knees, hips and the lumbo-sacral and thoraco-lumbar spinal junctions. Cervico-thoracic net intersegmental moment was calculated in a descending manner. RESULTS: Based on average recordings, clinical interpretation of net intersegmental moments (in N.m) showed a dorsal flexion on the ankles (8.6 N.m), a flexion on the knees (7.5 N.m) and an extension on the hips (8.5 N.m). On the spinal junctions, it was flexion moments: 0.34 N.m on the cervico-thoracic; 6.7 N.m on the thoraco-lumbar and 0.65 N.m on the lumbo-sacral. Evaluation of experimental error measurement showed a small inter-trial error (intrinsic variability), with higher inter-session and inter-therapist errors but without important variation between them. For one volunteer the “radiographic” posture was associated to significant changes compared to the free standing position. CONCLUSION: These initial results confirm the technical feasibility of the protocol. The low intrinsic error and the small differences between inter-session and inter-therapist errors seem to traduce postural variability over time, more than a failure of the protocol. Characterization of sagittal intersegmental net moments can have clinical applications such as evaluation of an unfused segment after a spinal arthrodesis.

Introduction La scoliose idiopathique thoracique de l’adolescent (SIA) est souvent associee a une hypocyphose thoracique. Cette deformation sagittale est responsable d’insuffisance respiratoire. Sa correction demeure difficile quelle que soit la technique chirurgicale employee. Certains auteurs ont souligne l’interet d’un premier temps de liberation anterieure afin reduire la hauteur de colonne anterieure et de corriger l’hypocyphose. Le but de cette etude est d’evaluer l’interet de la thoracoscopie pour corriger l’hypocyphose dans les SIA. Materiel et methode Cinquante-six patients avec une hypocyphose (T4T12 Resultats Les resultats des 2 groupes etaient comparables en termes de donnees demographiques et de cyphose pre-operatoire (groupe 1 – 11,7 ± 6,9 versus groupe 2 – 12,1 ± 6,3, p = 0,89). Le gain de cyphose post-operatoire dans le groupe 1 etait de 18,3 ± 13,6, et de 15,2 ± 9,0 dans le groupe 2. Au dernier recul, 75 % des patients du groupe 1 etaient normocyphotiques et 85 % du groupe 2. Dans chaque groupe, l’amelioration de la cyphose thoracique a ete significative (p Discussion La liberation anterieure par thoracoscopie reste une technique sure et reproductible. Cependant, les resultats de ce travail ne montrent pas de benefice significatif pour la correction sagittale, quand la technique de translation postero-mediale avec liens sous-lamaires est utilisee, meme dans les hypocyphoses severes. L’interet de la thoracoscopie reste a evaluer dans les grandes lordoscolioses. Conclusion L’arthodese posterieure hybride avec translation postero-mediale permet une restauration satisfaisante du profil des SIA. La liberation anterieure n’apporte pas de correction supplementaire.

Object The optimal management of unstable thoracolumbar fractures remains unclear. The objective of the present study was to evaluate the results of using an expandable prosthetic vertebral body cage (EPVBC) in the management of unstable thoracolumbar fractures. Methods Eighty-five patients with unstable T7–L4 thoracolumbar fractures underwent implantation of an EPVBC via an anterior approach combined with posterior fixation. Long-term functional outcomes, including visual analog scale and Oswestry disability index scores, were evaluated. Results In a mean follow-up period of 16 months, anterior fixation led to a significant increase in vertebral body height, with an average gain of 19%. However, the vertebral regional kyphosis angle was not significantly increased by anterior fixation alone. No significant difference was found between early postoperative, 3-month, and 1-year postoperative regional kyphosis angle and vertebral body height. Postoperative impaction of the prosthetic cage in adjacent endplates was observed in 35% of the cases, without worsening at last follow-up. Complete fusion was observed at 1 year postoperatively and no cases of infections or revisions were observed in relation to the anterior approach. Conclusions The use of EPVBCs for unstable thoracolumbar fractures is safe and effective in providing long-term vertebral body height restoration and kyphosis correction, with a moderate surgical and sepsis risk. Anterior cage implantation is an alternative to iliac bone graft fusion and is a viable option in association with a posterior approach, in a single operation without additional risks.