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The talus is a central bone in the hindfoot that is difficult to access surgically. Performing a medial or lateral malleolar osteotomy in the management of an osteochondral lesion of the talus (OLT) is a feared procedure amongst surgeons and their patients. The objective of this study was to assess the complications inherent to malleolar osteotomies in the treatment of OLTs. Hypothesis: The use of a standardized protocol concerning the technical performance and osteosynthesis of malleolar osteotomies results in fewer postoperative complications than a non-standardized protocol. Materials and method: This is a comparative study comprising a prospective multicenter non-randomized series with a standardized protocol for performing malleolar osteotomies, and a multicenter retrospective series without a standardized protocol. We included all patients aged 16 to 65 years with symptomatic OLTs, resistant to more than 6-months of well-conducted medical treatment, for whom surgery was considered. The minimum follow-up was 1 year for the prospective study, and 5 years for the retrospective study. A total of 86 and 97 patients were included in the prospective and retrospective studies, respectively. Of these 183 patients, 86 patients (33 prospective and 53 retrospective) underwent medial or lateral malleolar osteotomies as part of their surgery for OLT. Complications specific to the osteotomy procedures such as scar tissue, surgical site infection, non-union, articular malunion, neurological lesions or surgical revision, were investigated. Results: No specific complication was found to be associated to the malleolar osteotomy. No surgical revision was directly linked to the osteotomy procedure. No significant difference was found between the two series. Discussion: There was no evidence of morbidity related specifically to medial or lateral malleolar osteotomies. A standardized protocol, subject to rigorous technical implementation, does not improve results after malleolar osteotomy. The fear associated with this malleolar osteotomy procedure seems unfounded. Level of evidence: IV

Introduction The analysis of osteochondral lesions of talus (OLT) is currently mostly descriptive, not permitting an understanding of the different nosological frameworks of these lesions. Better knowledge of the characteristics of patients with OLT should make it possible to optimize the surgical indications and anticipate the associated lesions, which should not be overlooked. The main objective of this study was, therefore, to assess the characteristics of patients with OLT, and to analyze the lesions encountered. Hypothesis OLTs correspond to variable entities responding to specific treatments. Material and method This was a prospective multicenter descriptive study including all patients operated on for an OLT, aged between 15 and 65 years, across 10 French specialist centers. The demographic, clinical and radiological data of the patients were analyzed. Results OLTs predominantly affect males and patients in their thirties. Two types of OLT should be distinguished: a lateral OLT; smaller and more superficial, most often presenting with painful instability, in the context of trauma, and a medial OLT; more frequent, wider and deeper. Discussion Two nosological frameworks exist for OLTs, and correspond to precise surgical indications: medial lesions of more than 10 mm2 and more than 5 mm in depth, with isolated anteromedial pain and significant functional impairment, most often idiopathic, generally requiring treatment by osteochondral autografts. Lateral lesions less than 5 mm in depth and less than 10 mm2, often superficial, following trauma or ankle laxity, associated with lateral ligament damage in one-third of cases, and a clinical presentation associated to instability and pain, requiring treatment most often by microfracture with associated ligament repair. Level of evidence III.

International audience; Bioresorbable devices are commonly used in traumatology. The biomechanical stability of these materials has improved in the past decade, and they have proven to be biologically non-hazardous, while their main advantage is that their use avoids reintervention for removal of the device. A prospective monocentric study was conducted: 24 patients presenting with a fracture that was amenable to osteosynthesis by small-diameter screws were included. These comprised ten tibial spine fractures, four osteochondritis dissecans of the distal femur, eight fractures of the medial epicondyle of the distal humerus, and two distal tibial apophyseal fractures. One or more screws were used that were made of a copolymer of poly-L-lactide-poly-D-lactide acid and trimethylene carbonate with a diameter of 2.8 mm. All patients were immobilized with a cast. Clinical and radiographic monitoring was conducted every month. The entire follow-up protocol had a duration of 24 months. One patient with osteochondritis dissecans presented with joint effusion. Joint stiffness at the time of cast removal resolved completely after 4 months, except for with three children (one epicondyle fracture, two tibial spine fractures). No subjective or objective instability could be detected by clinical examination. Radiographic follow-up revealed no secondary displacement, and all of the fractures had healed. No osteolysis was seen around the screws. No growth disturbances were noticed. Bioresorbable materials thus appear to be a suitable alternative approach for certain pediatric fractures. Their use resulted in outcomes similar to traditional techniques in terms of functional properties and bone healing. Although initial costs are presumably slightly higher, by avoiding a removal operation the total financial burden is most likely reduced.

Background/purpose Intracranial calcifications have been identified in many neurological disorders. To our knowledge, however, such findings have not been described in cartilage-hair hypoplasia – anauxetic dysplasia spectrum disorders (CHH-AD), a group of conditions characterized by a wide spectrum of clinical manifestations. Methods/results We report a 22-year old female patient, diagnosed with this disorder during her first year of life, and in whom bilateral intracranial calcifications (frontal lobes, basal ganglia, cerebellar dentate nuclei) were discovered by brain MRI at the age of 17 years. Conclusion The etiology of this finding remains unclear. Some causes of such deposits can be of a reversible nature, thus prompting early recognition although their consequences on clinical outcome remain mostly unknown.

International audience; Kingella kingae is an important cause of invasive infections in young children from Western countries. Although increasing reports indicate that this organism is the leading agent of bone and joint infections in early childhood, data on K. kingae infections from resource-limited settings are scarce, and none has yet been reported in Africa. We herein report the diagnostic and epidemiological investigations of the first case of K. kingae arthritis identified in a child from sub-Saharan Africa. A 5-year-old Cameroonian boy presented with a sudden painful limp which appeared in the course of a mild rhinopharyngitis. He lived in Cameroon where he had been vaccinated with BCG at birth and moved to France for holidays 4 days before consultation. There was no history of trauma and he did not have any underlying medical condition. Upon admission, he had a temperature of 36.7 degrees C, and clinical examination revealed right-sided knee tenderness and effusion that was confirmed by ultrasound imaging. Laboratory results showed a white blood cell count of 5,700 cells/mm(3), C-reactive protein level of 174 mg/L, and platelet count of 495,000 cells/mm(3). He underwent an arthrocentesis and was immediately given intravenous amoxicillin-clavulanate. Conventional cultures from blood samples and synovial fluids were negative. Polymerase chain reaction (PCR) assay targeting the broad-range 16S rRNA gene and real-time quantitative PCR assays targeting Mycobacterium species were negative. Surprisingly, real-time PCR assays targeting the cpn60, rtxA, and rtxB genes of K. kingae were positive. Multicolor fluorescence in situ hybridization specific for K. kingae identified the presence of numerous coccobacilli located within the synovial fluid. Finally, multilocus sequence typing analysis performed on deoxyribonucleic acid directly extracted from joint fluid disclosed a novel K. kingae sequence-type complex. This case report demonstrates that K. kingae may be considered as a potential cause of septic arthritis in children living in sub-Saharan Africa, and hence the burden of K. kingae infection may be not limited to the Western countries. Further studies are required to determine the prevalence of K. kingae infection and carriage in Africa.

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Background Outbreaks of Kingella kingae infection are an emerging public health concern among daycare attendees carrying epidemic clones in the oropharynx. However, genotyping of such epidemic clones from affected cases is limited by the low performance of current methods to detect K. kingae from blood samples and lack of specimens available from infected sites. We aimed at developing a modified multilocus sequence typing (MLST) method to genotype K. kingae strains from oropharyngeal samples without prior culture. We designed in silico MLST primers specific for K. kingae by aligning whole nucleotide sequences of abcZ, adk, aroE, cpn60, recA, and gdh/zwf genes from closely related species belonging to the Kingella and Neisseria genera. We tested our modified MLST protocol on all Kingella species and N. meningitidis, as well as 11 oropharyngeal samples from young children with sporadic (n = 10) or epidemic (n = 1) K. kingae infection. Results We detected K. kingae-specific amplicons in the 11 oropharyngeal samples, corresponding to sequence-type 6 (ST-6) in 6 children including the epidemic cases, ST-25 in 2 children, and 3 possible novel STs (ST-67, ST-68, and ST-69). No amplicon was obtained from other Kingella species and N. meningitidis. Conclusions We herein developed a specific MLST protocol that enables genotyping of K. kingae by MLST directly from oropharyngeal samples. This discriminatory tool, with which we identified the first K. kingae outbreak caused by ST-6 in Europe, may be used in further epidemiological investigations. Electronic supplementary material The online version of this article (10.1186/s12866-017-1104-5) contains supplementary material, which is available to authorized users.

International audience; QUESTIONS UNDER STUDY/PRINCIPLES:To assess the usefulness of several laboratory and radiological investigations for the limping child with suspected transient synovitis of the hip.METHODS:The medical records of children admitted at our children's hospital for nontraumatic hip pain between 1999 and 2007 were retrospectively reviewed. During the study period, all children without a definite diagnosis after routine investigations in the emergency department were admitted and a specific work-up including antinuclear antibodies titre, rheumatoid factor, antistreptolysin O titre, Lyme disease serology and hip ultrasonography were obtained. Children were systematically re-evaluated 6 weeks after hospital discharge, with a clinical examination and radiological hip views. Patients were diagnosed with transient synovitis of the hip if an ultrasound-confirmed hip effusion was present at time of admission, complete resolution of symptoms occurred without any specific treatment, and no other pathology of the hip was identified during follow-up.RESULTS:A total of 417 cases without definite diagnosis were admitted and were submitted to a specific work-up. Transient synovitis of the hip was subsequently diagnosed in 383 patients, septic arthritis in 1 patient, and Lyme arthritis in 1 patient. Thirty-two patients remained without diagnosis. No rheumatological condition was found.CONCLUSION:Our results suggest that most investigations performed during the initial work-up in patients suspected transient synovitis of the hip are unnecessary and should routinely include only white blood cell count, C-reactive protein, erythrocyte sedimentation rate, and hip radiography and ultrasonography. No further investigations are necessary during follow-up for transient synovitis of the hip in asymptomatic children.

International audience; IntroductionThe development of reconstructive surgery of the lower limbs aimed at multilevel correction demands a precise knowledge of the physiological variations in general radiological parameters of the lower limbs in children of various age groups. It is crucial in systemic skeletal diseases, when deformities affect limbs and the surgeon does not have an intact limb as a reference. The aim of this retrospective study was to establish the normal radiological values of lower limb parameters used in the surgical correction of deformities in children of various age groups.Material and methodsTeleradiographs of the lower limbs taken in children with unilateral congenital or posttraumatic deformity were retrospectively reviewed. Weight-bearing full-length anteroposterior radiographs of the entire lower extremities were taken in a standing position. The study involved 215 extremities of 208 children (93 girls and 115 boys); the ages ranged from 2 years 1 month to 15 years 11 months old. Key variables included the anatomic medial proximal femoral angle (aMPFA), anatomic lateral distal femoral angle (aLDFA), anatomic medial proximal tibial angle (aMPTA), anatomic lateral distal tibial angle (aLDTA), mechanical axis deviation (MAD), the angle formed by the femoral anatomical axis and the mechanical axis of the lower limb.ResultsThe means and dynamics of variations, standard deviations (SD) and 95 % confidence intervals of each parameter were calculated for each age and gender group. Simple regression analysis was performed to determine the relationship between the patient’s age and the magnitude of aMPFA, aLDFA, aMPTA and aLDTA. Simple regression analysis showed a significant inverse correlation between patient age and the magnitude of aMPFA: the correlation coefficient was −0.77. A statistically significant inverse correlation between the MAD and the angle between the anatomic femoral axis and mechanical limb axis was found: the correlation coefficient was −0.53.ConclusionIn general, the received values were concordant to results of other studies. It concerned the MAD, aLDFA, aMPTA and angle between the mechanical limb axis and anatomic femoral axis. This is the first chronological evaluation of aMPFA and aLDTA from a relavively large series of patients. These normative data should be taken into consideration when evaluating lower limb alignment in children or applied in practice for planning and evaluation of the quality of surgical correction of complex deformities.

Background Lower limb deficits have been widely studied during gait in cerebral palsy, deficits in upper body have received little attention. The purpose of this research was to describe the characteristics of trunk movement of cerebral palsy children in terms of type of deficits (diplegia/hemiplegia) and gross motor function classification system (1, 2 or 3). Methods Data from 92 cerebral palsy children, which corresponds to 141 clinical gait analysis, were retrospectively selected. Kinematic parameters of trunk were extracted from thorax and spine angles in the sagittal, transverse and coronal planes. The range of motion and the mean positions over the gait cycle were analysed. Intra-group differences between the children with diplegia or hemiplegia, gross motor function classification systems 1 to 3 and typically developing participants were analysed with Kruskal–Wallis tests and post hoc tests. Pearson correlation coefficients between the gait profile score normalised walking speed and kinematic parameters of the thorax were assessed. Findings The results revealed: 1) the range of motion of the thorax and spine exhibited more significant differences between groups than the mean positions; 2) greater levels of impairment were associated with higher thorax range of motion, and 3) the children with diplegia and gross motor function classification system 3 exhibited a greater range of motion for all planes with the exception of spine rotation. Interpretation This study confirmed that greater levels of impairment in cerebral palsy are associated with greater thorax range of motion during gait. The thorax plays an important role during gait in cerebral palsy.

International audience; BACKGROUND:Evolution; Gait; Hereditary spastic paraplegia; Longitudinal study; WalkingThe degree of disability in patients with hereditary spastic paraplegia has been reported variable even in members of the same family (same gene mutation). Moreover, it has been established that patients with hereditary spastic paraplegia should be treated differently from cerebral palsy patients due to the progressive nature of this disease. However, the gait evolution of hereditary spastic paraplegia showing onset symptoms at an early age has been described as stable. Therefore, this study aims to evaluate the walking ability and the influence of treatments on gait evolution in a family with hereditary spastic paraplegia.METHODS:Clinical gait analyses were performed in six hereditary spastic paraplegia patients from the same family with a follow-up of 4-15 years.RESULTS:Based on the gait deviation index, results showed a large variation of walking ability in these patients and no statistical difference between the first and last examination. In fact, three patients have improved their gait (from childhood to adolescence) whereas three patients worsened their gait.CONCLUSIONS:Gait alterations in a family with hereditary spastic paraplegia are heterogeneous. Gait evolution in hereditary spastic paraplegia with early symptoms had a tendency to improve gait until adolescence with adapted treatments and to decline in the adulthood.

International audience; INTRODUCTION:Untreated growing patients with congenital scoliosis and fused ribs will develop finally thoracic insufficiency syndrome. The technique of expansion thoracoplasty with implantation of a vertical expandable prosthetic titanium rib (VEPTR) was introduced initially to treat these children.METHODS:This article attempts to provide an overview of the surgical technique of opening-wedge thoracostomy and VEPTR instrumentation in children with congenital thoracic scoliosis and fused ribs.RESULTS:Our modification of the surgical approach using a posterior midline incision rather than the modified thoracotomy incision initially described could potentially help to diminish wound dehiscence and secondary infection, while preserving a more acceptable esthetic appearance of the back.CONCLUSIONS:Vertical expandable prosthetic titanium rib-based treatments should be undertaken only with a good knowledge of its numerous specific complications. Every aspect of the treatment should be oriented to minimize these complications. At the same time it should be kept in mind that the ultimate step of this long-term fusionless treatment strategy will be a technically demanding spine fusion.

International audience; The mucopolysaccharidoses (MPS) are genetic lysosomal storage diseases. Peripheral bone dysplasia and spinal involvement are the predominant orthopedic damage. The risk of spinal cord compression due to stenosis of the craniocervical junction is well known in these patients, whereas the thoracolumbar kyphosis is often well tolerated over a long period of time. Thus, signs of spinal cord compression at this level occur later and more insidiously. The authors describe three cases of patients with thoracolumbar kyphosis who suffered from postoperative spinal cord compression in the absence of direct surgical trauma. Analysis of these cases and review of the literature helped identify causal factors resulting in spinal cord ischemia. The risk of perioperative spinal cord complications related to a thoracolumbar kyphosis must be discussed with patients with MPS and their families prior to any surgery, including extra-spinal procedures.

International audience; Background: Magnetic resonance imaging (MRI) is becoming more popular in the evaluation of residual hip dysplasia. Normal values of the bony, cartilaginous, and labral coverage in MRI are not published. The aim of our study was to establish reference values for normal hips at different ages and to assess the interobserver variability of such measurements.Methods: MRIs of 115 normal hips in 73 children were analyzed. The bony, cartilaginous, and labral acetabular index (AI bone/cartilage/labrum) was measured in the coronal plane just posterior to the inferior branch of the triradiate cartilage. To determine interobserver variability, measurements were made by 3 different observers. Percentile graphs were established from the Student t distribution of the measurements grouped by 2 years of age.Results: Global interobserver variability for the measurement of the AI bone was excellent [intraclass correlation coefficient (ICC)=0.88]. For the AI cartilage and labrum the ICC was somewhat lower (ICC 0.78) but still rated as good. Age-dependent percentile graphs of the AI bone, cartilage, and labrum are presented. Although the AI bone decreased during childhood, the AI cartilage as well as the AI labrum stays relatively constant with the 50 percentile around 5 degrees for the AI cartilage and −5 degrees for the AI labrum. The 90 percentile is around 10 degrees for the AI cartilage and 0 degrees for the AI labrum.Conclusions: We present percentile graphs of age-related normal values. Although bony coverage increases during childhood, cartilaginous and labral coverage stay constant. We think that measuring an AI cartilage above 10 degrees or an AI cartilage above 0 degrees might be a good additional parameter to classify hips into the group of residual dysplasia.Clinical Relevance: The knowledge of normal values for cartilaginous and labral coverage is a valuable adjunct in decision-making for secondary surgery in residual dysplasia. This was a retrospective cross-sectional study.

International audience; The course of the spondylodiscitis’ infantile form is characterized by a mild-to-moderate clinical and biologic inflammatory response. Unfortunately, blood and disk/vertebral aspiration cultures show a high percentage of negative results. However, detecting Kingella kingae DNA in the oropharynx provided reasonable suspicion, to our opinion, that this microorganism is responsible for the spondylodiscitis.

International audience; BACKGROUND:Postoperative axial deviations and delayed unions are possible complications after flexible intramedullary nailing (FIN). The goals of this study were to determine if a correlation exists between occurrence of the above complications and the ratio of the diameter between nail and medullary canal [nail diameter (ND)/MCD ratio], to study the interobserver variability in the measurement of MCD, and to define a threshold to be respected to optimize the results.METHODS:Eighty-one consecutive diaphyseal fractures treated by means of FIN were evaluated. The ND/MCD ratios were determined by 2 independent observers. Axial deviations were defined as 5-degree angulation or more observed before bone union. Absence of bone union at 3 months was considered as delayed union. Statistical analysis was made for interobserver variability of MCD, dependency between occurrence of complications and ND/MCD ratio and eventual confounding variables (age, weight, sex, and fracture location).RESULTS:Of the 81 fractures, 14 presented with an axial deviation and 3 with a delayed union. Interobserver variability of MCD diameter was excellent (intraclass correlation: 0.96). Occurrence of the above complications was significantly associated with a low ND/MCD ratio (P=0.0002) but with none of the examined confounding variables. Receiver operating characteristic analysis showed absence of complications with a ND/MCD ratio >35% with a sensitivity of 100% and specificity of 89%. Related with the MCD measurements variability, a safe threshold of 40% can be suggested.CONCLUSIONS:In FIN, ND>40% to the MCD should be chosen to avoid complications, besides respecting the technical principles. Measuring the medullary canal diameter in order to choose correct nail size is reproducible between different observers. In adolescents with a medullary canal diameter of >10 mm in femur or tibia fractures, alternative methods of osteosynthesis than FIN should be considered.SIGNIFICANCE:This work statistically confirms that a ND/MCD ratio of >40% must be respected to avoid some complications in FIN.

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