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Resume Introduction La planification 3D et l’utilisation de guides de coupe sur mesure sont de plus en plus utilisees dans les deformations squelettiques. Notre hypothese etait que cette technique est fiable et entraine peu de comorbidite dans les osteotomies de l’avant-bras chez l’enfant. Materiel et methodes Vingt-trois enfants ayant subi une ou plusieurs osteotomies de corrections pour une deformation de l’avant-bras ont ete inclus retrospectivement : 9 operes avec guide de coupe (G+) soit 20 osteotomies et 14 sans guide de coupe (G−) soit 28 osteotomies. Les etiologies etaient 8 deformations de Madelung (3G+ et 5G−) et 15 cals vicieux post-traumatiques (6G+ et 9G−). L’âge moyen a la chirurgie etait de 14,8 ± 1,9 ans. Les guides de coupe sur mesure, fabriques en polyamide par une imprimante 3D, etaient developpes a partir des modeles virtuels 3D issus de la reconstruction tridimensionnelle d’un scanner. Le suivi moyen etait de 22,1 ± 13,6 mois. Resultats Les erreurs moyennes de correction etaient respectivement de 5,3° ± 4,1 et de 4,2° ± 4,1 dans les plans frontal et sagittal (p = 0,6) dans le groupe G+. La chirurgie a ete significativement plus rapide dans le groupe G+ (difference moyenne = 42 minutes ; p = 0,02). Les doses moyennes d’irradiation totale (scanner preoperatoire et fluoroscopie peroperatoire) etaient significativement plus elevees dans le groupe G+ que dans G− (p Conclusion Ces resultats preliminaires sont encourageants et demontrent que la planification 3D et l’utilisation de guides de coupe sur mesure peuvent etre envisagees dans la prise en charge des deformations de l’avant-bras chez l’enfant. Niveau de preuve III ; etude de cohorte retrospective.

Scaffolds are an essential component of bone tissue engineering. They provide support and create a physiological environment for cells to proliferate and differentiate. Bone allografts extracted from human donors are promising scaffolds due to their mechanical and structural characteristics. Bone microarchitecture is well known to be an important determinant of macroscopic mechanical properties, but its role at the microscopic, i.e., the trabeculae level is still poorly understood. The present study investigated linear correlations between microarchitectural parameters obtained from X-ray computed tomography (micro-CT) images of bone allografts, such as bone volume fraction (BV/TV), degree of anisotropy (DA), or ellipsoid factor (EF), and micromechanical parameters derived from micro-finite element calculations, such as mean axial strain (εz) and strain energy density (We). DAEF, a new parameter based on a linear combination of the two microarchitectural parameters DA and EF, showed a strong linear correlation with the bone mechanical characteristics at the microscopic scale. Our results concluded that the spatial distribution and the plate-and-rod structure of trabecular bone are the main determinants of the mechanical properties of bone at the microscopic level. The DAEF parameter could, therefore, be used as a tool to predict the level of mechanical stimulation at the local scale, a key parameter to better understand and optimize the mechanism of osteogenesis in bone tissue engineering.

Palliative surgery in a child with incomplete recovery following obstetric brachial plexus birth palsy (BPBP) is common. Surgical management strategies for BPBP sequelae have the common objectives of decreasing the risk of functional limitations in the long term and improving function. There is no single treatment to deal with the sequelae of BPBP. While there is a myriad of possible clinical presentations, the ages for surgery extend from a 6- to 12-month-old infant to the mature adolescent. Numerous procedures have been described in the literature, ranging from simple soft tissue release to muscular transfers and osteotomies. The indications will depend on a combination of all these factors. In certain cases, an early intervention is recommended to prevent joint deformities, and to allow joint remodeling, often at the shoulder. In other cases, the indications are less clear, thus the expected benefit must be carefully considered. The indications for these operations must meet certain rules to be beneficial for the patient and should only be considered after a comprehensive clinical examination and a commitment from the child and the family to the therapeutic strategy.

BACKGROUND: Clinical examination is the gold standard for surgical indication. Electromyogram and conventional MRI are insufficient to understand the highly variable clinical presentation of neonatal brachial plexus (BP) lesions. Diffusion Tensor Imaging is based on motion of water molecules and can explore nerve function. PURPOSE: This pilot study of healthy subjects aimed to develop a new method for BP exploration using MRI. The main objective was to obtain complete and accurate BP mapping using DTI and MRI tractography. METHODS: Six healthy volunteers had MRI (3T PRISMA) with anatomical 3D STIR, SPACE and RESOLVE diffusion sequences. Image analysis and processing was performed with MATLAB software. Diffusion parametric maps of fractional anisotropy (FA) were extracted from RESOLVE acquisitions. A reproducible method for root volume and angle measurements was created using 3DSlicer. Regions Of Interest were segmented on Mean B0 sequences. FA measurements were obtained with ROI on Mean B0 sequences. RESULTS: RESOLVE sequence was adapted to the BP. Mean FA was 0.30. Angle measurements on 3D STIR SPACE sequences showed increasing values from proximal to distal roots with an ICC of 0.6. Volume measurements on anatomical sequences varied widely from one root to another but no significant difference was shown on laterality. CONCLUSION: A new and reproducible method for BP exploration was developed using MRI RESOLVE diffusion sequences. Complete mapping was obtained despite low track density imaging resolution. The whole BP was visualized. Extraction of diffusion, volume and angle parameters of the plexus roots, and script creation for image processing was adapted to the healthy BP.

Objective: The main objective of this study was the development of a non-invasive mathematical marker of the skin surface, the characteristic length, to predict the microstructure of the dermis. This marker, at the individual level, is intended to provide the biological age of the patient in the context of personalised medicine for the elderly. Study design: To validate this hypothesis, a clinical study was conducted on 22 women over 60 years old from a population of osteoporotic subjects who sustained a femoral neck fracture: a morphological analysis of the skin surface was performed on the patient’s forearm and quantitatively compared with microarchitectural parameters of the dermis. Major results: The Elastin-to-Collagen ratio measured on dermis samples ranged between 0.007 and 0.084, with a mean of 0.035 ± 0.02. The surface characteristic length ranged between 0.90 and 2.621, with a mean of 0.64 ± 0.51. A very strong correlation was found between this characteristic length and the Elastin-to-Collagen ratio (r = 0.92). Conclusions: This study proposes an original diagnostic tool based on morphometric indices of the skin surface and shows a direct quantitative relationship with the dermis microarchitecture and its collagen and elastin content. The proposed method allows reliable and easy access to the intrinsic ageing of the dermis, which would be a strong biomarker in a personalised collagen treatment approach.

In children suffering from brachial plexus birth injuries (BPBI), one major difficulty concerns intraoperative selection of the roots to be used for reconstruction. Between November 2018 and August 2020, surgical qualitative evaluations and pathological quantitative analyses were conducted on 52 roots and 29 distal neural stumps (trunks, divisions, cords, and nerves distal to the neuroma) in 17 patients who underwent brachial plexus reconstruction. For each root, surgeons rated stump quality as "good", "fair" or "avulsed". Neural sections were then sent to pathology to determine percentage intraneural fibrosis under microscopy. Mean root intraneural fibrosis rates were 30.5% (SD 24.9; range, 0-80%), 46.3% (SD 32.6; range, 0-90%) and 24.6% (SD 23.5; range, 0-80%) in the "good quality", "fair quality" and "avulsed" groups, respectively, with no significant differences between groups. In distal neural stumps, the mean intraneural fibrosis rate was 30.9% (SD 24.7). These findings raise the question of conducting frozen section biopsy of neural stumps after neuroma resection to determine surgical reconstruction strategy.

Outcomes measurements after pollicization remains difficult due to the lack of a standardized assessment protocol. This study reports our experience of a global assessment of pollicized thumbs that includes a specific questionnaire for subjective evaluation, a detailed clinical assessment focused on functional outcomes incorporating function and usage of the pollicized thumb. Twenty-seven patients completed the questionnaire, and nine hands were clinically evaluated by a multidisciplinary team composed of hand surgeons and occupational therapists. Subjective evaluations revealed that 24 patients would recommend pollicization. Clinical evaluations revealed that only four out of nine patients properly integrated their pollicized thumb during bimanual activities; however, occupational therapy input allowed the children to compensate for the lack of strength and other difficulties. We propose the use of this global assessment package to analyse function and usage at various capacities, which can be useful for the surgeon, child and parents. Level of evidence: IV

Defined as the union of two adjacent digits, syndactyly is one of the most common congenital deformities. The severity of the malformation depends on the fusion level, the tissues involved in the union, and whether it is isolated or syndromic. In order to improve the hand's appearance and function, surgery is recommended in the great majority of cases, ideally during early childhood (i.e., before entering school). Web space reconstruction is done using local flaps. Depending on the flap design, digital resurfacing can be done with or without skin grafts. While graftless techniques have shorter operating times and no morbidity associated with skin harvesting, their cosmetic outcomes seem to be worse than those of traditional grafting techniques, with more postoperative complications; furthermore, such techniques cannot be used in all cases, especially those with osteoarticular fusions. When the fingertip is involved, paronychial reconstruction is carried out with pulp flaps. The prognosis for these deformities directly depends on their severity, with excellent outcomes in cases of cutaneous fusion, and much less predictable ones when osteoarticular and/or tendinous tissues are involved.

Radial club hand deformities are commonly treated with arthrolysis to allow centralization of the ulna. In this retrospective cohort study of 31 hands in 28 patients, we aimed to assess the outcomes of correction using progressive distraction and subsequent percutaneous pinning of the wrist with a corrective ulnar osteotomy. Mean follow-up time was 7 years (range 2 to 20). The angulation of the hand–forearm complex was decreased after each step of the procedure. Mean correction of the angulation was 64°, and the residual total forearm–hand angulation was 12° after completion of the surgery. At the time of bony maturity (four patients), all wrists had fused. Fifty-eight reoperations were required in 31 wrists because of pin migration or breakage, and in addition 18 secondary osteotomies of the ulna were performed. From this study we conclude that distraction and pinning provide satisfactory and stable realignment of the wrist to correct the deformity, but this treatment has drawbacks regarding the high number of reoperations and the loss of wrist mobility. Level of evidence: IV

From 1998 to 2014, we performed primary brachial plexus repair in 260 children with neonatal brachial plexus palsy. Thirty-three presented with a C5-8 palsy and 24 were reviewed for this study. The surgical strategy was to focus on repairing the upper trunk. Secondary surgical procedures were performed in 21 patients, mainly for shoulder external rotation deficit or weak wrist extension. After a mean follow-up of 9.7 years (range 3 to 19), the median Mallet score for the shoulder was 9.5 and the mean Raimondi score for the hand was 3.3. Median active movement scale was 5, 7 and 5.5 for the deltoid, biceps and triceps, respectively. We conclude that primary C5-8 brachial plexus reconstruction provides restoration of elbow flexion and most patients have a sensitive and functional hand. We also found that secondary surgery to improve shoulder and wrist function is often necessary, which should initially be explained to the family. Level of evidence: IV

Background: In more than 50% of cases, anterior cruciate ligament (ACL) lesions lead to post-traumatic osteoarthritis. Ligament reconstruction stabilizes the joint, but the tear seems to impair the poroelasticity of the cartilage: synovial membrane fluid inflammation is observed 3 weeks after tearing. There have been some descriptions of visible cartilage changes, but poroelasticity has never been analyzed at this early stage. The present animal study aimed to determine 1) whether cartilage showed early poroelastic deterioration after ACL tear; 2) whether impairment correlated with macroscopic changes; and 3) whether cartilage poroelasticity deteriorated over time. Hypothesis: In the days following trauma, cartilage poroelasticity is greatly impaired, without macroscopically visible change. Material and methods: ACL tear was surgically induced in 18 New-Zealand rabbits. Cartilage poroelasticity was assessed on indentation-relaxation test in 3 groups: “early”, at 2 weeks postoperatively (n=6), “mid-early” at 6 weeks (n=6) and in a non-operated control group (“non-op”). Macroscopic changes were scored in the same groups. Results: Poroelastic impairment was greatest at the early time-point (2 weeks). Permeability ranged from a mean 0.08±0.05x10-15 m4/Ns (range, 0.028-0.17) in the “non-op” group to 1.03±0.60x10-15 m4/Ns (range, 0.24-2.15) in the “early” group (p=0.007). Shear modulus ranged from 0.53±0.11 MPa (range, 0.36-0.66) to 0.23±0.10 MPa (range, 0.12-0.43), respectively (p=0.013). Macroscopic deterioration, on the other hand, differed significantly only between the “mid-early” and the “non-op” groups: p=0.011 for cartilage deterioration and p=0.008 for osteophyte formation. At the “mid-early” time point, poroelastic deterioration was less marked, with 0.33±0.33x10-15 m4/Ns permeability (range, 0.06-1.06) and shear modulus 0.30±0.10 MPa (range, 0.13-0.41: respectively p=0.039 and p=0.023 compared to the “non-op” group. Discussion: The severe rapid deterioration in poroelasticity following ACL tear in an animal model, as notably seen in increased permeability, corresponds to changes in cartilage microstructure, with easier outflow of interstitial fluid. This mechanical degradation may underlie onset of microcracks within the cartilage, leading to physiological loading that the cartilage by its nature is unable to repair. Further investigations are needed to correlate these experimental data with clinical findings. Level of evidence: III; comparative study with control group.

Resume Introduction Le transfert d’epiphyse proximale vascularisee de fibula associe a un segment de diaphyse permet de traiter les pertes de substances epiphysaires de l’enfant. L’objectif de cette etude est d’analyser la technique chirurgicale, puis les resultats cliniques et radiologiques a long terme. Materiel et methode Entre 1997 et 2008, 7 patients, âges en moyenne de 5,7 ans (2–8), ont ete operes d’une tumeur osseuse maligne avec reconstruction par transfert d’epiphyse vascularisee de fibula : 5 sarcomes d’Ewing et 2 osteosarcomes, localises au femur proximal (3), a l’humerus proximal (3) et au radius distal (1). Le transplant mesurait en moyenne 13,8 cm. La vascularisation etait assuree par un pedicule unique dans 5 cas (fibulaire : 3 ; tibial anterieur : 2) et par deux pedicules dans 2 cas. L’osteosynthese etait realisee par une broche centromedullaire dans 6 cas et une plaque vissee dans 1 cas. Tous les patients ont eu une chimiotherapie pre- et postoperatoire selon les protocoles de la societe francaise d’oncologie pediatrique. Resultats Le recul moyen etait de 11 ans (de 3 ans et 11 mois a plus de 17 ans). Tous les patients etaient vivants et en remission de leur tumeur. La fonction de l’articulation reconstruite etait jugee satisfaisante dans 85 % des cas. L’epaississement du greffon traduisait son integration dans tous les cas. La physe transferee avait repris sa croissance dans 4 cas. Parmi les complications, on notait une infection postoperatoire, deux defauts de consolidation, 8 fractures, une desaxation necessitant une reprise chirurgicale et deux paralysies spontanement regressives du nerf fibulaire commun. Discussion Chez les petits enfants, le transfert de fibula vascularisee avec son epiphyse est une technique qui permet a la fois de combler une perte de substance osseuse, de reconstruire une articulation mobile et de permettre la poursuite de la croissance du segment reseque. Les protheses de croissance, selon l’experience des auteurs, ont regulierement donne de mauvais resultats dans cette tranche d’âge et les arthrodeses ne reglent pas le probleme de la croissance. Il semble important de prevenir les patients du risque de fracture pouvant survenir, meme a long terme. Conclusion Le transfert d’epiphyse vascularisee est une technique difficile, grevee de complications, mais qui permet de reconstruire un segment osseux emportant une epiphyse chez le petit enfant, conservant ainsi une fonction et une croissance. Niveau d’evidence III, etude clinique retrospective.

Introduction Vascularized fibular proximal epiphyseal transfer associated to a diaphyseal segment is used to treat childhood epiphyseal defect. The aim of the present study was to analyze surgical technique and long-term clinical and radiological results. Material and method Between 1997 and 2008, 7 patients with a mean age of 5.7 years (range, 2-8 years) were operated on for bone malignancy with vascularized fibular epiphyseal transfer: 5 Ewing sarcomas and 2 osteosarcomas, located in the proximal femur (n = 3), proximal humerus (n = 3) or distal radius (n = 1). Mean transplant size was 13.8 cm. Vascularization involved a single artery in 5 cases (3 peroneal, 2 anterior tibial) and both in 2 cases. Internal fixation used intramedullary nailing in 6 cases and screwed plate in 1. All patients underwent pre- and post-operative chemotherapy following French Pediatric Oncology Society (SFOP) protocols. Results Mean follow-up was 11 years (range, 3 years 11 months to > 17 years). All patients were alive and in tumor remission. Reconstructed joint function was satisfactory in 85% of cases. Graft thickening indicated integration in all cases. The transferred cartilage had recovered growth in 4 cases. Complications comprised postoperative infection (n =1), consolidation defects (n = 2), fractures (n = 8), malalignment requiring surgical revision (n = 1), and spontaneously resolving common peroneal nerve palsies (n = 2). Discussion In young children, vascularized fibular epiphyseal transfer fills bone defect, reconstructs a functional joint and allows continued growth in the resected segment. Growth prostheses, in the authors’ experience, always give poor results in this age-group, and fusion fails to address the growth problem. Patients should be informed about the risk of fracture, persisting over the long term. Conclusion Vascularized fibular epiphyseal transfer is a difficult technique, subject to complications, but enables reconstruction of a bone segment involving the epiphysis in young children, conserving function and growth. Level of evidence III, retrospective clinical study.

Background Amputation of the abnormal segment seems to be the reference standard treatment for the surgical management of macrodactyly of the foot in children. Our objectives here were to detail the surgical strategies according to the cause, anatomical characteristics, and static or progressive nature of the macrodactyly and to evaluate the long-term clinical outcomes. Hypothesis Conservative treatment can be an option in the management of static macrodactyly of the foot in children. Material and methods We retrospectively included 24 feet in 19 patients seen consecutively. There were 12 primary and 12 secondary types. The macrodactyly was static in 9 cases and progressive in 15 cases. The treatment consisted in either conservative procedures or amputation of the segment. All patients completed the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) to evaluate their quality of life, shoe wear issues, and satisfaction with their treatment. Results Mean age at first surgery was 5.8 years (range, 0.5–11.5) and the mean interval between two procedures was 2.3 years (range, 0.3–5.5). Mean number of procedures per foot was 2.2 par pied (range, 0–7). All 9 static forms were managed conservatively. Amputation was performed in 11 of the 15 progressive forms. The mean number of procedures was significantly higher in the progressive forms (4.1 vs. 1.5/pied; p = 0.006). Two patients died during follow-up. The remaining 17 patients, with 22 affected feet (primary and secondary in 11 cases; progressive in 14 cases and static in 8 cases) were re-evaluated. Mean follow-up was 9.4 years (range, 2.7–20.6). The final OxAFQ-C score was 46/60 (range, 18–58). Of the 17 patients, 86% would be willing to repeat the same surgical procedures and 77% were satisfied with their treatment at last follow-up. We found no differences between the groups managed with amputation and with conservative treatment regarding quality of life, satisfaction, or shoe size difference. Conclusions Conservative treatment deserves a place in the treatment of static macrodactyly of the foot in children. Regarding amputation of the segment in progressive forms, it is important to reassure the patients and parents about the expected results but also to inform them about the risk of requiring repeat surgical procedures. Level of evidence IV, retrospective study.

Introduction Three-dimensional (3D) planning and patient-specific surgical guides are increasingly used in the treatment of skeletal deformities. The present study hypothesis was that they are reliable in forearm osteotomy in children, with low morbidity. Material and methods Twenty-there children with one or several osteotomies to correct forearm deformities were retrospectively included: 9 (20 osteotomies) with surgical guide (G+), and 14 (28 osteotomies) without (G-). Etiologies comprised 8 cases of Madelung disease (3G+, 5G−) and 15 of post-traumatic malunion (6G+, 9G−). Mean age at surgery was 14.8 ± 1.9 years. The patient-specific 3D-printed polyamide guides were produced from 3D virtual models based on 3D CT reconstruction. Mean follow-up was 22.1 ± 13.6 months. Results Mean correction error was 5.3° ± 4.1 and 4.2° ± 4.1 in the frontal and sagittal planes respectively in G+ (p = 0.6). Surgery time was significantly shorter in G+, by a mean 42 min (p = 0.02). Mean total radiation dose (preoperative CT + intraoperative fluoroscopy) was significantly higher in G+ (p Conclusion The present preliminary results were encouraging. 3D planning and patient-specific surgical guides can be used in the treatment of forearm deformity in children. Level of evidence III; retrospective cohort study.

In cases of brachial plexus birth injury with internal rotation contracture of the shoulder, the subscapularis muscle may be released proximally, from the subscapular fossa, or distally, along with periarticular soft tissues arthroscopic to the glenohumeral joint. We hypothesized that the indication for each procedure would rely primarily on patients' bone remodeling potential and periarticular soft-tissue contractures, performing proximal releases in patients aged4 years and periarticular distal releases in older patients. The purpose of this study was to analyze the outcomes such a strategy could provide.All patients presenting with brachial plexus birth injury-related shoulder internal rotation contractures who underwent a subscapularis release were included; in addition, to restore the joint axial balance, the infraspinatus was systematically reanimated with a tendon transfer (ie, latissimus dorsi or lower trapezius) during the same operating time. Chart review yielded preoperative and postoperative clinical and radiographic measurements, including active and passive range of motion of the shoulder in external rotation (ER) with the arm at the side of the body, the modified Mallet score, glenoid version, and the percentage of the humeral head arthroscopic to the middle of the glenoid process.Between July 2012 and January 2018, 28 children were operated on at our institution. In patients who underwent proximal subscapularis release (n = 13), significant improvements were observed regarding active shoulder ER, passive shoulder ER, the modified Mallet score, glenoid version, and the percentage of the humeral head arthroscopic to the middle of the glenoid process, averaging 58° ± 32° (P.0001), 56° ± 20° (P.0001), 9.7 ± 3.1 points (P = .0006), 15° ± 10° (P = .0034), and 24% ± 20% (P = .0113), respectively, after a mean follow-up period of 4 years. Following distal release procedures (n = 15), these improvements averaged 26° ± 29° (P = .0024), 27° ± 28° (P = .0011), 3.3 ± 4.1 points (P = .0049), 2° ± 17° (P = .4086), and 4% ± 18% (P = .215), respectively, after a mean follow-up period of 3 years.When combined with axial rebalancing of the joint, the proximal release of the subscapularis muscle appears to be sufficient to provide satisfactory functional outcomes in patients with great bone remodeling potential and supple periarticular soft tissues. In older patients, a more comprehensive release of the glenohumeral joint's arthroscopic aspect seems to provide lower but still significant clinical improvements.

Tissue-engineered grafts may be useful in Anterior Cruciate Ligament (ACL) repair and provide a novel, alternative treatment to clinical complications of rupture, harvest site morbidity and biocompatibility associated with autografts, allografts and synthetic grafts. We successfully used supercritical carbon dioxide (Sc-CO2) technology for manufacturing a “smart” biomaterial scaffold, which retains the native protein conformation and tensile strength of the natural ACL but is decellularized for a decreased immunogenic response. We designed and fabricated a new scaffold exhibiting (1) high tensile strength and biomechanical properties comparable to those of the native tissue, (2) thermodynamically-stable extra-cellular matrix (ECM), (3) preserved collagen composition and crosslinking, (4) a decellularized material milieu with potential for future engineering applications and (5) proven feasibility and biocompatibility in an animal model of ligament reconstruction. Because of the “smart” material ECM, this scaffold may have the potential for providing a niche and for directing stem cell growth, differentiations and function pertinent to new tissue formation. Sc-CO2-related technology is advanced and has the capability to provide scaffolds of high strength and durability, which sustain a lifetime of wear and tear under mechanical loading in vivo.

The objective of this study was to evaluate the results after selective pronator teres (PT) neurectomy in children with spastic hemiplegia. Patients with PT spasticity without contracture and an active supination improvement after PT botulinum toxin injection were included. Hand function and deformities were evaluated with the House score, Gschwind and Tonkin pronation deformity classification and Zancolli’s classification. Twenty-two patients (mean age 11.6 years) were included in this study. The average follow-up was 32.6 months. All but one patient improved their supination with a preoperative mean active supination of 5° (range −80–70°) and postoperative of 48° (range 10–90°). Active pronation was always maintained at the last follow-up. PT selective neurectomy appears to improve active and passive forearm supination and should be included in a global strategy of treatments to improve upper limb function in children with cerebral palsy. Level of evidence: IV

BACKGROUND Extension-type supracondylar fractures can be treated with external immobilization, with the elbow flexed 100°. However, this technique requires early evaluation by true lateral x-ray of the elbow to detect secondary fracture displacement. QUESTIONS/PURPOSE The purpose of this work is to evaluate whether ultrasound imaging is suitable for demonstrating initial reduction of supracondylar fractures and early secondary displacement of the fracture. METHODS Fourteen patients aged 3 to 7 years (mean, 4.8 years) were treated by closed reduction under general anesthesia and immobilization with a collar and cuff. All patients had early postoperative x-rays and ultrasonography on day 1, as well as day 8 x-rays and ultrasonography. Ultrasonograms were performed by an experienced senior radiologist. RESULTS In all cases, a complete reduction was confirmed at initial follow-up on both sonogram and intraoperative fluoroscopy. In 13 of 14 cases, no secondary displacement of the fracture was noted at day 8 on either ultrasonography or x-ray images. In 1 case, a secondary displacement was noted at day 8 on ultrasonography and confirmed by the lateral x-ray. CONCLUSIONS Our study found a complete agreement assessing the quality of intraoperative reduction of supracondylar fractures by radiographs and ultrasonography. These results confirm that ultrasound imaging is suitable for demonstrating secondary displacements of supracondylar fractures in children. We postulate that in Gartland types II and III fractures treated by Blount procedure, a negative ultrasound result at day 8 follow-up may reduce the need for further radiographs. However, in any doubtful situation, the need for conventional radiographs remains. LEVEL OF EVIDENCE Diagnostic study, level II.

Resume Etat de l’art Les strategies d’ingenierie tissulaire comportent des therapies cellulaires par transfert direct ou mobilisation des cellules. Les structures ligamentaires sont hautement specialisees et un element essentiel de l’appareil musculo-squelettique. Les lesions ligamentaires sont responsables d’importantes pertes fonctionnelles. Hypothese Le but de cette etude est d’analyser l’integration d’un greffon tendineux, son repeuplement cellulaire et sa « ligamentisation » en utilisant un modele de reparation ligamentaire chez le lapin transgenique gene fluorescent protein (GFP). Materiel et methode La technique de transplantation tendineuse a ete mise au point pour s’approcher le plus possible des conditions de realisation d’une reparation du ligament croise anterieur. Les allogreffes tendineuses ont ete implantees dans 8 lapins New Zealand White et evalues a 5 jours, 3 semaines et 6 semaines par un arthroscanner, l’analyse morphologique de l’allogreffe transplantee, une analyse histologique, l’immunohistochimie du collagene de type I dans le transplant, et le typage cellulaire GFP. Les modifications collageniques ont ete evaluees a 3 semaines et 6 semaines. Resultats La colonisation des allogreffes par les cellules de l’hote (cellules de type chondrocyte a l’interface entre le tendon et l’os) et la corticalisation des tunnels osseux ont ete notees a 3 semaines. Une necrose centrale de l’allogreffe transplantee dans sa portion intra-articulaire a ete notee a 6 semaines avec une migration cellulaire depuis les zones peripheriques de l’allogreffe a proximite de la synoviale. Discussion Notre etude apporte de nouvelles connaissances sur la comprehension de l’integration a l’os d’une allogreffe tendineuse ainsi que sur les phenomenes de colonisation cellulaire d’une allogreffe et son processus de « ligamentisation ». Nous pensons que les deux strategies de transfert direct cellulaire et de colonisation secondaire sont benefiques a la qualite du resultat final au niveau du transplant. Des etudes ulterieures pourraient permettre d’elucider les etapes de cette colonisation cellulaire en provenance de cellules pre-differentiees ou pro-genitrices. Niveau d’evidence Niveau V (etude animale).

Purpose: The aim of this study was to compare the radiation dose, image quality and 3D spine parameter measurements of EOS low-dose and micro-dose protocols for in-brace adolescent idiopathic scoliosis (AIS) patients. Methods: We prospectively included 25 consecutive patients (20 females, 5 males) followed for AIS and undergoing brace treatment. The mean age was 12 years (SD 2 years, range 8-15 years). For each patient, in-brace biplanar EOS radiographs were acquired in a standing position using both the conventional low-dose and micro-dose protocols. Dose area product (DAP) was systematically recorded. Diagnostic image quality was qualitatively assessed by two radiologists for visibility of anatomical structures. The reliability of 3D spine modeling between two operators was quantitatively evaluated for the most clinically relevant 3D radiological parameters using intraclass correlation coefficient (ICC). Results: The mean DAP for the posteroanterior and lateral acquisitions was 300 ± 134 and 433 ± 181 mGy cm2 for the low-dose radiographs, and 41 ± 19 and 81 ± 39 mGy cm2 for micro-dose radiographs. Image quality was lower with the micro-dose protocol. The agreement was "good" to "very good" for all measured clinical parameters when comparing the low-dose and micro-dose protocols (ICC > 0.73). Conclusion: The micro-dose protocol substantially reduced the delivered dose (by a factor of 5-7 compared to the low-dose protocol) in braced children with AIS. Although image quality was reduced, the micro-dose protocol proved to be adapted to radiological follow-up, with adequate image quality and reliable clinical measurements. These slides can be retrieved under Electronic Supplementary Material. No funding was secured for this study.

Evaluer les resultats a moyen terme apres centralisation par une technique en 2 temps dans les mains botes radiales severes. Une etude retrospective observationnelle a ete conduite parmi les patients operes pour agenesie radiale de 1994 to 2016. La reaxation a ete effectue par allongement par distraction externe par fixateur externe double rail suivi d’une centralisation par broche centromedullaire. La correction etait evaluee par plusieurs mesures radiologiques relevees en preoperatoire et au dernier recul : l’angle forme entre l’axe de M3 et l’ulna proximal, l’angle forme entre l’axe de M3 et la perpendiculaire a l’epiphyse ulnaire, la translation mesuree par la distance entre la base de M3 et l’ulna distal et la courbure de l’ulna mesuree par l’angle entre l’axe de l’ulna proximal et l’axe de l’ulna distal. Trente et une mains botes radiales ont beneficie d’un traitement de reaxation : 5 presentaient une agenesie radiale type 2,2 de type 3 et 24 de type 4. L’inclinaison radiale moyenne etait de 64 degres. L’âge moyen a la premiere intervention etait de 2 ans. Les patients ont beneficie de 5 interventions en moyenne. La duree moyenne de suivi est de 5 ans (extremes : 1 a 11 ans). L’angulation moyenne M3-ulna proximal residuelle moyenne etait de 17 degres, la correction moyenne etait de 49 degres. La complication la plus frequente etait la migration des broches ou l’insuffisance de leur longueur secondaire a la croissance. La technique de distraction-reduction en deux temps permet une meilleure conservation dans le temps de la reduction que les techniques sur les parties molles et s’affranchit des complications suite aux liberations extensives des parties molles et aux resections carpiennes. Elle respecte la croissance de l’ulna distale et est plus simple que les techniques de transfert d’os vascularise. La technique en deux temps de distraction par fixateur externe puis centralisation par broche permet de bons resultats a long moyen terme. La complication principale est la migration des broches de centralisation. Des avancees technologiques concernant le materiel qui suivrait l’allongement de l’ulna pendant la croissance permettrait de limiter ces complications.

Resume La prise en charge actuelle, multidisciplinaire, et les progres realises font que la survie des patients atteints de tumeurs de l’appareil locomoteur s’est nettement amelioree. Nous devons tenir compte des sequelles orthopediques a long terme dans nos choix chirurgicaux, dues au traitement chirurgical lui-meme (amputation ou conservation de membre – choix du type de reconstruction), mais aussi dues aux therapeutiques associees (chimiotherapie, radiotherapie). Les reconstructions par allogreffe ont des complications durant les trois premieres annees (infections, fractures, pseudarthroses). Passe ce cap, la longevite des allogreffes est correcte, mais a 10 ans de recul, 60 % auront ete otees. Pour ce qui est des protheses articulaires, leur survie globale est de 75 % a 10 ans et de 52 % a 20 ans. Comme pour les allogreffes, les ennuis infectieux surviennent dans les premieres annees. Les changements de prothese plus tardifs sont lies a des causes mecaniques. Il est beaucoup plus difficile de se faire une idee du devenir a long terme des reconstructions plus biologiques du fait du manque de recul, excepte pour les fibula vascularisees qui ont de bons resultats a long terme. La qualite de vie des patients operes d’une tumeur maligne de l’appareil locomoteur a ete l’objet de nombreux articles qui, pour la plupart, comparent les conservations de membre avec les amputations. Globalement, les resultats semblent equivalents. Toutes ces donnees sont a prendre en compte lorsqu’on decide d’un traitement pour un enfant ou un adolescent. La qualite de vie, la fonction du membre atteint, la necessite ou non de reintervenir incitent a proposer des reconstructions, lorsque cela est possible, qui se rapprochent au mieux de l’anatomie normale. Nos connaissances restent fragmentaires du fait de la difficulte d’organiser un suivi sur un tres long terme. Nous ne pourrons progresser qu’en organisant des filieres de soins entre chirurgien d’enfants et chirurgien d’adultes.

The foot may be the site of birth defects. These abnormalities are sometimes suspected prenatally. Final diagnosis depends on clinical examination at birth. These deformations can be simple malpositions: metatarsus adductus, talipes calcaneovalgus and pes supinatus. The prognosis is excellent spontaneously or with a simple orthopedic treatment. Surgery remains outstanding. The use of a pediatric orthopedist will be considered if malposition does not relax after several weeks. Malformations (clubfoot, vertical talus and skew foot) require specialized care early. Clubfoot is characterized by an equine and varus hindfoot, an adducted and supine forefoot, not reducible. Vertical talus combines equine hindfoot and dorsiflexion of the forefoot, which is performed in the midfoot instead of the ankle. Skew foot is suspected when a metatarsus adductus is resistant to conservative treatment. Early treatment is primarily orthopedic at birth. Surgical treatment begins to be considered after walking age. Keep in mind that an abnormality of the foot may be associated with other conditions: malposition with congenital hip, malformations with syndromes, neurological and genetic abnormalities.

Tendon lengthening and transfer are usually indicated for certain neuromuscular disorders, peripheral or central nerve injury, congenital disorder or direct traumatic or degenerative musculotendinous lesion. In musculotendinous lengthening, technique depends on muscle anatomy, degree of correction required, and the need to avoid excessive loss of force. Lengthening within the muscle or aponeurosis is stable. In the tendon, however, it may provide greater gain but is not stable and requires postoperative immobilization to avoid excessive lengthening. Tendon transfer consists in displacing a muscle's tendon insertion in order to restore function. The muscle to be transferred is chosen according to strength, architecture and course, contraction timing, intended direction, synergy and the joint moment arm to be restored. Functions to be restored have to be prioritized, and alternatives to transfer should be identified. The principles of tendon transfer require preoperative assessment of the quality of the tissue through which the transfer is to pass and of the suppleness of the joints concerned. During the procedure, transfer tension should be optimized and the neurovascular bundle should be protected. The method of fixation, whether tendon-to-bone or tendon-to-tendon suture, should be planned according to local conditions and the surgeon's experience.

Every doctor can be confronted, during his career, with patients presenting symptoms they created themselves. Because it is easily accessible, the hand is a favored target organ for these self-inflicted injuries. The diagnosis of factitious disorder of the hand is very difficult, rarely suggested and widely under-estimated. The real issue is detecting it early on to develop a cohesive diagnostic and therapeutic approach. The three clinical cases reported in this article illustrate the difficulty of caring for this pathology at all stages, from diagnosis to treatment. These disorders must be distinguished from malingering. A psychiatrist must be part of the treatment team. The prognosis of factitious disorders is poor. It is vital to maintain contact with the patient once the diagnosis is established. The risk is that the patient consults with other professionals, restarting a new cycle. The featured clinical cases were chosen to remind surgeons that factitious disorders of the hand are a recognized psychiatric disease. It must be evoked in the context of an unusual injury with a vague history. Everything possible must be done to confirm the diagnosis and avoid surgery.

OBJECTIVE: To determine whether the seasonal distribution of Kingella kingae osteoarticular infections is similar to that of common respiratory viruses. STUDY DESIGN: Between October 2009 and September 2016, we extracted the results of K kingae-specific real-time polymerase chain reaction analyses performed for bone or joint specimens in patients from 2 pediatric tertiary care centers in Paris. We used data of respiratory virus detection from the Réseau National des Laboratoires network with coordination with the National Influenza Center of France. The Spearman rank correlation was used to assess a correlation between weekly distributions, with P

International audience; OBJECTIVES:Fractures of the lateral humeral condyle are common in children. Nondisplaced fractures are managed with cast immobilization and frequent radiographic follow-up. Possibility of assessing the displacement and stability of such fractures may be helpful in planning the initial treatment and survey. Magnetic resonance imaging (MRI) could be a useful tool in determining the stability of lateral condyle in children. We propose to investigate the use of MRI in such indication.METHODS:Fourteen patients presenting with a minimally displaced or nondisplaced fracture were initially treated with a long arm cast and had an MRI within 5 days of injury.RESULTS:The MRI showed that 10 patients had an incomplete fracture without disruption of the cartilage hinge and 4 patients had a complete fracture with extension of the fracture through the cartilaginous epiphysis into the elbow joint. Three patients with such complete fracture had no evidence of lateral condyle displacement on MRI, and 1 patient had a displacement of the lateral condyle. The patients with incomplete fractures had a conservative treatment. The patient with a complete and displaced fracture had an open reduction and internal fixation. The 3 patients with a complete fracture and no evidence of lateral condyle displacement on MRI had a control MRI, 6 to 10 days after cast application, to detect a secondary displacement of the fracture.CONCLUSIONS:Because it seems difficult in minimally displaced or nondisplaced fractures to detect further displacement with radiographs, MRI was found mandatory to improve complete fracture visualization during the first phase of conservative treatment. In incomplete fractures, initial MRI investigation was consistent with a stable fracture and avoided further early radiographs or clinical survey. In such cases, we recommend a conservative treatment with late radiographs after long arm cast removal. We propose MRI routine use in the early evaluation of minimally displaced or nondisplaced lateral condyle fractures in children.

International audience; Purpose: Scoliosis with pelvic obliquity (PO) could be investigated with the EOS-CHAIR protocol as the most common deformity especially in patients with trunk hypotonia and quadriplegia. However, the intra-observer and inter-observer reliability of various angles assessing PO was not investigated with this new imaging protocol.Methods: A retrospective cohort of 36 EOS frontal full-spine acquisitions made in sitting position was used. The sacroiliac pelvic obliquity angle, iliac crest pelvic obliquity angle, and ischiatic pelvic obliquity angle were assessed in an intra-observer and inter-observer study.Results: The use of the EOS-CHAIR protocol was implemented satisfactory with a high acceptance rate by all caregivers and patients and their families. Intra-observer and inter-observer reliability was excellent for the three tested angular measurements.Discussion: As for idiopathic scoliosis, we postulate the EOS system as being superior to standard radiographs to assess 3D spinal deformities in neuromuscular conditions. The EOS-CHAIR protocol improves preoperative comprehension of the lumbosacral junction anatomy in patients with poor standing or sitting postures. Our results show a very high reliability of three different angular measurements of the frontal pelvic obliquity in sitting position. Then it is possible to use one of these three angles as well as the others to assess frontal pelvic obliquity in neuromuscular patients. This frontal pelvic obliquity protocol in sitting position with the EOS-CHAIR is a validated measurement technique that needs to be used now to measure PO as a critical parameter of the global trunk balance in neuromuscular patients.

Resume La scoliose est une deformation qui atteint frequemment les patients porteurs de maladies neurologiques ou musculaires. Ces deformations importantes de la colonne vertebrale peuvent occasionner des difficultes de maintien de la position assise. Les traitements orthopediques et chirurgicaux des scolioses neuromusculaires different des traitements des scolioses idiopathiques par leur plus grande complexite et le risque plus important de survenue de complications. Le traitement orthopedique parvient rarement a controler totalement une scoliose neuromusculaire evolutive. Son but est de prevenir et de limiter les deformations vertebrales secondaires a l’hypotonie ou aux contractions musculaires anormales. Le traitement orthopedique par corset le plus souvent a temps plein doit etre modifie et adapte tout au long de la periode de croissance et peut etre source de gene fonctionnelle et de perte d’autonomie. Les corrections chirurgicales necessitent une prise en charge et une evaluation multidisciplinaire peri-operatoire. L’obliquite pelvienne est frequemment associee a la deformation rachidienne d’origine neurologique ou musculaire. Elle peut rendre difficile le maintien de la position assise et sa correction doit etre prise en compte dans la planification de la strategie operatoire. Le but de la correction chirurgicale de ces deformations est d’obtenir une correction satisfaisante de la colonne vertebrale au-dessus d’un bassin correctement positionne dans l’espace. L’evaluation multidisciplinaire preoperatoire permet d’anticiper d’eventuelles difficultes liees au terrain : l’evaluation respiratoire permet d’envisager une ventilation non invasive peri-operatoire et doit etre completee par une evaluation nutritionnelle et psychosociale incluant la poursuite de la prise en charge globale au decours du geste chirurgical. La mise en œuvre de cette prise en charge globale permet d’obtenir un resultat chirurgical et fonctionnel satisfaisant chez la tres grande majorite des patients.

La extension a la pelvis de una osteosintesis raquidea esta justificada en el tratamiento de algunos tumores raquideos o de deformaciones graves de la charnela lumbosacra, a menudo de origen neurologico. Las condiciones locales son malas en ocasiones, porque el sacro suele ofrecer un anclaje mediocre, mientras que las tensiones aplicadas sobre el material son significativas. Las osteosintesis lumbopelvicas se asocian a una mayor morbilidad que las osteosintesis raquideas solas. La osteosintesis puede fijarse unicamente en el sacro (atornillado intrasacro, placa sacra, tecnica de Dunn-McCarthy) o extenderse al ala iliaca (tecnica de Galveston, atornillado iliaco). Otras tecnicas asocian una sujecion distribuida entre el ala iliaca y el sacro con distintos sistemas segmentarios (placas sacras, tornillos iliosacros o montaje segmentario bi-iliosacro). Con independencia de cual sea la tecnica utilizada, la extension a la pelvis de las osteosintesis raquideas sigue siendo un procedimiento quirurgico complejo que requiere una reflexion estrategica individualizada y una ejecucion tecnica impecable. La curva de aprendizaje es muy prolongada, sobre todo en los pacientes fragiles, delgados y osteoporoticos, o que tengan modificaciones de la anatomia lumbopelvica.

Scoliosis surgery may be associated with a high morbidity and even mortality in children with non-idiopathic scoliosis. The aim of the study was to report our experience with a pre-operative training to non-invasive positive pressure ventilation (NPPV) and a mechanical insufflator-exsufflator (MI-E) device to improve the post-operative respiratory outcome of children scheduled for scoliosis surgery.Consecutive patients with non-idiopathic scoliosis undergoing posterior arthrodesis were trained to NPPV and MI-E before intervention. NPPV and MI-E were performed immediately after extubation. Length of intubation and intensive care unit (ICU) stay, duration of NPPV, and respiratory complications were assessed.Thirteen patients participated in the training (mean age 13.9 ± 2.6, mean vital capacity 52.3 ± 15.4% predicted). The patients had severe respiratory muscle weakness with a mean sniff oesophageal pressure of 35.8 ± 14.2 cmH2O (50% predicted) and a mean gastric pressure during a cough of 31.9 ± 7.8 cmH2O (30% predicted). The mean length of intubation was 19.9 ± 12.3 h with a mean length of ICU stay of 2.5 ± 2.5 days. NPPV was used during a mean of 2.7 ± 1.9 days after surgery. No respiratory complication was observed. One patient died 3 months after surgery from multi-organ failure of non-respiratory origin.No respiratory complications were observed after scoliosis correction surgery in children with non-idiopathic scoliosis after pre-operative training and post-operative use of NPPV and MI-E, underlying the interest of this management in these high-risk patients.

L’estensione alla pelvi di un’osteosintesi del rachide e giustificata nel trattamento di alcune neoplasie del rachide o deformazioni severe della cerniera lombosacrale, spesso di origine neurologica. Le condizioni locali sono di frequente sfavorevoli poiche il sacro offre un ancoraggio mediocre, mentre il materiale e sottoposto a uno sforzo notevole. Le osteosintesi lombopelviche sono associate a una maggiore morbilita rispetto alle osteosintesi del rachide. L’osteosintesi puo essere fissata unicamente al sacro (fissaggio a vite intersacrale, placca sacrale, tecnica di Dunn-McCarthy) o estesa all’ala iliaca (tecnica di Galveston, fissaggio a vite iliaco). Altre tecniche associano un ancoraggio distribuito tra l’ala iliaca e il sacro con diversi sistemi segmentari (placche sacrali, viti iliosacrali o montaggio segmentario bi-iliosacrale). Indipendentemente dalla tecnica, l’estensione al bacino delle osteosintesi del rachide resta una procedura chirurgica delicata che necessita di uno studio approfondito caso per caso e di una realizzazione tecnica impeccabile. La curva di apprendimento resta difficile, soprattutto nei pazienti fragili, magri, osteoporotici o con anatomia lombopelvica modificata.

Les deformations post-traumatiques ou malformatives des deux os de l’avant-bras sont souvent responsables d’une gene fonctionnelle, douloureuses et/ou esthetique. Lorsqu’une correction chirurgicale est indiquee, l’analyse des deformations et la planification des osteotomies est parfois complexe. Elle est neanmoins facilitee par la reconstruction tridimensionnelle du segment antebrachial. Grâce a l’impression tridimensionnelle, cette reconstruction permet aussi la fabrication d’ancillaires chirurgicaux personnalises. Les objectifs de cette etude sont l’evaluation de la fiabilite de ces ancillaires et leur benefice sur la realisation et la duree de l’acte chirurgical. Six avant-bras de six patients d’âge median 13,9 ans (10,6–17,3) et tous operes en 2018 ont ete inclus. Il s’agissait de trois cals vicieux post-traumatiques, d’une epiphysiodese du radius distal et deux deformations de Madelung. Les osteotomies des deux os de l’avant-bras ont ete realisees grâce a des ancillaires sur mesure. Ils etaient concus par impression tridimensionnelle au cours d’une planification preoperatoire avec des ingenieurs sur des scanners des 2 avant-bras. Ils etaient composes d’un guide d’osteotomie et d’un guide de preforage des vis de la plaque d’osteosynthese. La reduction apres osteotomie s’effectue sur des plaques d’osteosynthese conformees en preoperatoire. La duree operatoire a ete quantifiee. Les complications per- et postoperatoires ont ete rapportees. Des mesures radiologiques postoperatoires ont ete comparees aux donnees de la planification. La correction de la deformation etait conforme a la planification dans tous les cas. La duree mediane de garrot etait de 120 min (90–120). Une paralysie radiale regressive a ete constatee en postoperatoire. Les ancillaires personnalises ont permis des corrections precises et conformes a la planification. La duree operatoire a ete reduite et devrait encore diminuer avec l’experience. Le bon positionnement des guides doit prendre en compte les parties molles, non representees sur les reconstructions osseuses lors de la planification, ainsi que leur encombrement, ce qui oblige a anticiper le type d’abord chirurgical. La fabrication de ces ancillaires represente neanmoins un cout non negligeable. Leur conception necessite a ce jour la realisation d’une tomodensitometrie source d’une irradiation supplementaire pour ces jeunes patients. Une alternative pourrait etre l’utilisation de coupes d’IRM. L’utilisation d’ancillaires personnalises pour la correction des deformations de l’avant-bras permet la realisation precise de la planification preoperatoire. Leur benefice semble superieur aux contraintes liees au temps passe a la planification preoperatoire.

International audience; Recently, it has been shown that constructs of poly(vinyl alcohol) (PVA) hydrogel fibers reproduce closely the tensile behavior of ligaments. However, the biological response to these systems has not been explored yet. Here, we report the first in vivo evaluation of these implants and focus on the integration in bone, using a rabbit model of bone tunnel healing. Implants consisted in bundles of PVA hydrogel fibers embedded in a PVA hydrogel matrix. Half of the samples were coated with a composite coating of hydroxyapatite (HA) particles embedded in PVA hydrogel. The biological integration was evaluated at 6 weeks using histology and micro-CT imaging. For all implants, a good biological tolerance and growth of new bone tissue are reported. All the implants were surrounded by a fibrous layer comparable to what was previously observed for poly(ethylene terephthalate) (PET) fibers currently used in humans for ligament reconstruction. An image analysis method is proposed to quantify the thickness of this fibrous capsule. Implants coated with HA were not significantly osteoconductive, which can be attributed to the slow dissolution of the selected hydroxyapatite. Overall, these results confirm the relevance of PVA hydrogel fibers for ligament reconstruction and adjustments are proposed to enhance its osseointegration.

Purpose Recently introduced cobalt-chromium (CoCr) rods that rely solely on pedicle screws produce very good results in correcting scoliotic curves. All-pedicle screws constructs are also suspected of decreasing thoracic kyphosis. The current study was designed to evaluate sagittal correction in adolescent idiopathic scoliosis patients, using 6-mm CoCr rods and all-screw constructs. Materials and methods A total of 61 patients treated by posterior spinal fusion and instrumentation, using all-pedicle screw constructs were included. The mean age at surgery was 15.4 years (range, 12-18 y). Forty-five patients (group A) were diagnosed with decreased thoracic kyphosis, and 16 patients (group B) had normal (35-50 degrees) thoracic kyphosis. Results The preoperative main Cobb angle was 62.93±19.38 degrees in group A and 73.45±22.13 degrees in group B. In group A, the postoperative main Cobb angle was 23.33±12.71 degrees. In group B, the postoperative main Cobb angle was 27.20±10.04 degrees. The T4-T12 thoracic kyphosis improved postoperatively from 18.15±10.29 to 28.18±8.35 degrees in group A. In group B, the postoperative T4-T12 thoracic kyphosis was 40.34±3.13 degrees. Statistical analysis showed a significant improvement between preoperative and postoperative values of T4-T12 thoracic kyphosis in group A. In group B, the differences in T4-T12 thoracic kyphosis values were not statistically significant. Conclusions Our result demonstrates a significant improvement of T4-T12 thoracic kyphosis in the hypokyphotic group of patients and confirms that CoCr rods can produce sagittal corrections in hypokyphotic adolescent idiopathic scoliosis patients. Our results confirm the benefit of combining all-pedicle screw constructs with a posterolateral translational in situ bending procedure to correct hypokyphosis directly.

International audience; Pedicle screw fixation allows purchase of all three spinal columns without encroaching into the spinal canal improving fracture fixation, as well as deformity correction. Fortunately, neurologic injury associated with pedicle screw malposition is rare.Case presentationA 19-year-old boy was surgically treated for severe right thoracic scoliosis associated with a Chiari Type 1 malformation and a C6 to T7 syringomyelia. Six months after the initial surgery, the patient was referred to our institution after three weeks of gait disturbances and repeated falls. Imaging showed the gross misplacement of the left T5 pedicle screw, which crossed the center of the vertebral canal. The initial surgery used a freehand technique of pedicle screw insertion, with anteroposterior and lateral postoperative X-ray control. During the surgery, no SEP modifications were noted during pedicle screw placement. However, after insertion of the second rod and scoliosis correction by posterior translation technique, SEP responses decreased considerably. Revision surgery was performed to remove the misplaced screw. During the first three months after screw removal, repeated clinical examinations showed progressive recovery of the neurological deficits. Gait and bladder functions were normal six months after screw removal, and clinical signs of spasticity disappeared. SEP explorations performed at final follow-up showed similar responses to those performed before the initial surgery for scoliosis correctionDiscussion and evaluationNeurologic injury associated with pedicle screw malposition is rare. In early or delayed neurological status worsening, intraoperative or postoperative imaging must be done to detect pedicle screw misplacement. In the current case, thanks to cobalt-chromium and titanium use, MRI and CT scan allowed good visualization of the spinal canal and spinal cord. Experimental studies have shown that neurophysiological monitoring of the spinal cord does not detect moderate compression. In that way, neurophysiological monitoring is an all-or-nothing technique which can misdiagnose early stage of spinal cord injuries. Major penetration of the spinal canal by pedicle screw may conduct to hardware removal.ConclusionsIn early or delayed neurological status worsening, intraoperative or postoperative imaging must be done to detect pedicle screw misplacement. In the current case, thanks to cobalt-chromium and titanium use, MRI and CT scan allowed good visualization of the spinal canal and spinal cord. Major penetration of the spinal canal by pedicle screw may conduct to hardware removal.

The treatment of acute hematogenous osteomyelitis has evolved in recent years to a shorter parenteral treatment with an early switch to the oral route. Current publications recommend a 2- to 4-day parenteral treatment before the oral switch. We retrospectively analyzed a series of 45 children aged 1 to 11 years and treated in our department for acute osteomyelitis without severity criterion. Nineteen of 45 patients were treated by an exclusive ambulatory oral treatment by amoxicillin and clavulanic acid. Twenty six of 45 patients had a 2- to 4-day parenteral treatment before the oral switch. The minimum follow-up was 6 months. The primary endpoint was a clinical, radiographic, and biologic healing, 6 months after the beginning of the treatment. The secondary endpoints evaluated were the length of hospitalization, the total duration of treatment, and the type of antibiotic used. On the primary endpoint, we did not find any significant difference between the 2 treatments (P = 0.38). On the duration of treatment, we found a significant difference (P = 0.049) in favor of oral treatment. The ambulatory oral treatment by amoxicillin and clavulanic acid seems to be a valid alternative to the classical parenteral then oral sequence in the treatment of acute hematogenous osteomyelitis in children without severity criterion.

Purpose Magnetic resonance imaging (MRI) has been successfully used in the determination of the adequacy of the surgical reduction of congenitally dislocated hips in children. We present the results of a prospective series of patients treated conservatively. MRI was performed in all hips after positioning was deemed adequate on radiographs after spica cast application. The goal of this study was to evaluate the usefulness of MRI in this indication. Methods After the study was approved by our local ethics committee, 31 patients for a total of 36 dislocated hips were included. After the traction period, hip testing was performed and a hip spica cast was applied under general anaesthesia. All children had MRI within 1 week of reduction, without the need for contention or general anaesthesia. Hip reduction was assessed on axial and coronal MRI images. Results The concentric reduction of the hip was confirmed in 30 cases out of 36. In three cases, the dislocation was retrospectively suspected on radiographs and then confirmed. In the three remaining cases, hip dislocation was only diagnosed on MRI. Conclusions MRI screening of congenitally dislocated hips after reduction procedures is a safe and reliable procedure to assess the concentric reduction of the hip. Even in doubtful cases, MRI detected persistent hip dislocations and was conducive to iterative reduction and satisfactory outcome and result.

Introduction Les ruptures du ligament croise anterieur sont en augmentation croissante chez l’enfant. Le risque d’atteinte meniscale et de degradation arthrosique prematuree expliquent l’evolution du nombre de ligamentoplastie chez l’enfant en croissance. Le dispositif GnRB est utilise en pratique clinique dans l’evaluation preoperatoire des ruptures du ligament croise anterieur chez l’adulte et dans l’evaluation postoperatoire des ligamentoplasties. L’enfant a une laxite peripherique intrinseque evolutive avec la croissance. L’objectif de cette etude est d’etudier la translation tibiale anterieure physiologique dans une population d’enfants sains permettant d’obtenir des valeurs de references et d’aider a l’analyse de l’evaluation pre- ou postoperatoire des ruptures du ligament croise anterieur chez l’enfant en croissance. Methode Soixante enfants de moins de 15 ans ont ete inclus dans cette etude prospective monocentrique menee entre novembre 2017 et avril 2018. Les criteres d’inclusion etaient : un âge compris entre 8 et 15 ans, aucun antecedent de pathologie ou de chirurgie du genou, aucune pathologie neuromusculaire. Trente filles et 30 garcons, repartis en trois tranches d’âge 8– > 10 ans, 10–12 ans et > 12–15 ans ont ete inclus sur la base du volontariat lors d’une consultation d’orthopedie. Un test de la laximetrie par le dispositif GnrRB etait realise a differentes poussees successives (134, 150 et 200 N). Un test de Student a ete utilise pour l’analyse statistique. Resultat Les valeurs de deplacement sur l’ensemble des enfants etaient respectivement a 134 N, 150 N et 200 N de 7,01 ± 2,7 mm ; 7,34 ± 2,59 mm et de 9,03 ± 2,57 mm. Il n’a pas ete montre de difference significative entre les genoux droit et gauche a chaque poussee (p = 0,09 ; 0,11 et 0,31). Il n’a pas ete montre de differences significatives entre les filles et les garcons. Les valeurs des trois groupes d’âge pour chaque poussee ont ete comparees. Il n’y a pas de difference significative dans le deplacement entre les differents groupes d’âge. Discussion En comparant les resultats avec la litterature, la laxite chez l’enfant semble superieure a l’adulte. Le dispositif GnRB est une technique validee chez l’adulte dans le diagnostic des ruptures et l’evaluation postoperatoire des ruptures du ligament croise anterieur, avec definition de valeurs seuils. Si le dispositif GnRB est utilisable en pratique clinique chez l’enfant des l’âge de 8 ans, l’existence d’une laxite physiologique doit etre prise en compte dans l’interpretation des resultats. Conclusion La translation tibiale anterieure physiologique semble etre evolutive avec la croissance, et doit etre pris en compte dans l’evaluation par laximetrie.