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Introduction La numerisation des donnees histopathologiques a ouvert la porte a des diagnostics plus rapides, reproductibles et precis, notamment en pathologie mammaire. Face a la penurie croissante et a l’âge avance des medecins pathologistes, des solutions de numerisation d’images ont ete mis au point. Ils allegent la charge du travail journaliere des pathologistes, ameliorent la precision des diagnostics et limitent le taux d’erreur. Objectif Evaluer la sensibilite et la specificite de deux algorithmes entraines sur une serie de lesions mammaires. Methodes Nous avons effectue une etude prospective portant sur 116 pieces operatoires mammaires realisees pour un carcinome mammaire invasif, traitees au laboratoire d’anatomie pathologique de l’Institut national d’oncologie de Rabat, sur une periode de 6 mois allant de janvier 2020 a juin 2020. Les diagnostics ont ete valides par un anatomopathologiste au microscope optique, avec une numerisation des lames colorees a l’HE, prises au grossissement ×200. La validation du diagnostic sur les lames numerisees a ete realisee par 3 pathologistes specialises en pathologie mammaire. Les regions d’interet ont concerne au total 328 images, classees en : carcinome invasif (groupe 2) ; carcinome in-situ (groupe 1), benin : lesions benignes et/ou structures normales (groupe 0). Toutes les donnees ont ete saisies selon une approche de machine learning basee sur 3 phases : pretraitement des donnees, extraction des caracteristiques et classification selon le reseau de neurones convolutionnels, et exposition des resultats sous forme de deux modeles d’algorithmes par calcul de la precision moyenne (average accuray) : ResNet et Xception. Resultats Nous avons analyse 328 images digitalisees, dont 152 groupe 0, 70 groupe 1 et 106 groupe 2. La concordance de la lecture par les trois pathologistes entre la lame en verre et numerique etait de 98,7 % des cas. L’entrainement sur les deux algorithmes a ete evalue par une validation croisee. L’Accuray etait de 84,5 % dans le modele ResNet, et de 88 % dans le modele Xception. Discussion En termes d’analyse d’images digitalisees, tous les pathologistes ont choisi de continuer a utiliser le microscope numerique comme standard pour le diagnostic morphologique des echantillons du sein avec le recours a la lame en verre pour un nombre limite de scenarios. Sur les algorithmes entraines utilises, la performance de precision etait plus elevee dans les deux groupes 0 (94 %) et 2 (80 %) par rapport au groupe 1 (70 %). Ceci peut s’expliquer par la difficulte du diagnostic et aussi par l’echantillonnage reduit du groupe 2. Conclusion Le recours a l’intelligence artificielle avec la methode du deep learning va revolutionner le travail, souvent repetitif et chronophage, du medecin anatomopathologiste, et dont l’objectif n’est pas de remplacer les professionnels de sante, mais de leur apporter une aide convaincante dans la detection du cancer du sein, et de sa prise en charge personnalisee.

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.

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.

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.

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.

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.

Les sarcomes mammaires representent moins de 0,1 % de l’ensemble des tumeurs malignes du sein. Les chondrosarcomes primitifs du sein sont extremement rares. Seulement six cas ont ete rapportes dans la litterature. Nous rapportons un cas supplementaire concernant une femme de 53 ans, presentant un nodule au niveau du sein droit augmentant rapidement de volume avec une ade nopathie axillaire du meme cote. La mammographie amontre une grosse opacite occupant presque la totalite du sein droit et une deuxieme opacite similaire au niveau du prolongement axillaire. L’e chographie abdominale a montre des localisations secondaires au niveau hepatique. Une biopsie chirurgicale a e te realisee, et l’etude morphologique associee a l’immunohistochimie a conclu a un chondrosarcome. Le chondrosarcome primitif du sein est extremement rare. Ce diagnostic ne peut etre retenu qu’apres avoir elimine un carcinosarcome et une tumeur phyllode avec differenciation chondroide. L’etude morphologique associee a l’immunohistochimie permet de les differencier. Le traitement est chirurgical, mais en cas de metastases, la prise en charge reste problematique du fait de la chimio- et de la radioresistance de ces tumeurs.

BACKGROUND: Multiple distraction strategies have been proposed to reduce the incidence of anxiety and pain in children. Animal-assisted therapy is acknowledged and used in children as an adjunctive treatment with cognitive, physical, psychosocial and spiritual benefits.OBJECTIVE: To determine the effect of fish aquarium animal-assisted therapy (FA-AAT) on pain perception in a cohort of healthy volunteers.METHODS: Sixty-nine healthy subjects (mean age 27.3 years) were exposed to >20 different species of soft or hard corals and >25 fish in a 1000 L saltwater aquarium. Pain perception was assessed using an electrical stimulation device, the Pain Matcher (Cefar Medical AB, Sweden), after 5 min, 10 min, 20 min and 30 min of continuous aquarium viewing. The measurements were repeated 10 min after stopping aquarium viewing.RESULTS: A statistically significant pain perception threshold augmentation was observed after a 5 min aquarium viewing. This threshold augmentation was also increased after 10 min, 20 min and 30 min of FA-AAT. A remnant effect was noted up to 10 min after exposure. This short post-viewing time period could be useful in clinical practice to perform certain painful procedures in children, such as those involving needles, under improved conditions immediately after aquarium exposure.CONCLUSIONS: In the authors’ department, FA-AAT is now used as a nonpharmacological antinociceptive technique in association with a protocol of inhalated oxygen/nitrous oxide mixtures for needle-related procedures. Children and parents are invited to watch the aquarium during the 10 min to 20 min before venous punctures.

Objectives Both bone forearm fractures are efficiently treated by elastic stable intramedullary nail (ESIN). According to the original technique, the tip of the nail must be bent at 90° and buried under the skin. However, skin irritation is commonly reported and may lead to early surgery to shorten the tip or remove the hardware. The purpose of this study was to investigate the influence of the bending of the tip of the nail in this procedure. Methods We retrospectively reviewed 72 children operated on using this technique with the tip bent either at 90° or at 180°. In both groups we recorded complication rates after the procedure and at the removal. Results Time until removal and duration of the removal were similar in both groups. Three complications (6.7%) that required additional surgery were recorded when the tip was bent at 90° whereas no complications were found with the tip bent at 180°. Conclusion We advocate bending the tip of the nail at 180° before burying it in order to avoid skin irritation and additional procedures. Level of evidence Level III—retrospective comparative study.

Pedicle screw fixation is considered biomechanically advantageous in adolescent idiopathic scoliosis (AIS) correction, because it uses as an anchor the pedicle, which is the hardest part of the vertebral body. The ability of the rod to correct and hold the correction is a key factor in the selection of rod material. The goal of this study was to compare the results obtained by stainless steel (SS) and cobalt–chromium (CoCr) rods materials for the treatment of AIS curves. Ninety patients were retrospectively included. Sixty-four patients (group 1) were operated on using CoCr rods. Twenty-six patients (group 2) were operated on using SS rods. All the patients were treated by the same surgeon using all-pedicle screw constructs. In group 1, the correction was respectively 41.03° and 35.78° for main and secondary curves. In group 2, the correction was respectively 30.98° and 24.42° for main and secondary curves. Statistical analysis showed improved correction rates in patients operated with CoCr rods for main (P

Desmoplastic ameloblastoma is a benign, locally aggressive neoplasm of proliferating odontogenic epithelial origin. It is seen among old patients from 17 to 72 years with an average age 42 years and without predilection of sex. We report the case of a 7 year old child, having presented since the 5 years age, a gingival tumefaction on the left higher incisivo-canin group which increased volume gradually. The stomatologic examination showed a gingival tumefaction covered with a healthy mucous membrane, ovoid form and measuring 3 cm on its horizontal axis. The tomodensitometry of the jawbone showed in front of the 21st and the 22nd tooth, the presence of an osseous lesion associating of the hearths of osteolysis and osteocondensation with rupture of cortical and invasion of the soft tissue. A curetting of the lesion was carried out and the anatomopathologic examination retained the diagnosis of desmoplastic ameloblastoma. The characteristic of our observation is the youth of the patient. In addition, the desmoplastic ameloblastoma is relatively rare, is characterized by an anatomical distribution, a radiological appearance and a morphological aspect differents from the traditional ameloblastoma. A radical surgical treatment is suggested for this tumour to avoid recurrency.

Analyser les resultats fonctionnels a long terme des fractures supra condyliennet traitees selon la technique de Blount. Etude retrospective menee entre 1988-2008 (stade 1 de Lagrange et Rigault exclus). Sont etudies : les deplacements secondaires, le nombre de reprise, les troubles trophiques et les complications neuro vasculaires. 169 enfant (57 stade 2, 53 stade 3 et 59 stade 4) ont ete revus a J8, J21 et J45 avec des radiographies standards. 22 enfants ont ete perdus de vue. Pour les non perdus de vue, le recul moyen est de 6 ans lors de la derniere consultation. Nous avons repertorie 32 reprises pour deplacement secondaires (62 % de stade 4) dont 10 ont eu un Blount iteratif et 22 ont ete operes. Quelques complications precoces de la technique ont ete retrouvees (trouble trophique, troubles neuro vasculaires,)mais toutes ont evolue favorablement. Les resultats montrent 70 % de recuperation complete de la mobilite articulaire apres ablation de la contention. Nous discutons de ces resultats a l’aide de la litterature. La methode de Blount reste une technique performante dans le traitement des fractures supra condyliennes humerales de l’enfant.

Background Pectus excavatum (PE) is a common congenital deformity. The Nuss technique for minimally invasive repair of PE involves thoracoscopy-assisted insertion of a bar or plate behind the deformity to displace the sternum anteriorly. Our objective here was to clarify the indications and limitations of the Nuss technique based on a review of 70 patients. Materials and methods A retrospective review of children managed at two centres identified 70 patients who had completed their growth and had their plate removed. Mean age was 13.8 years (range, 6–19 years). The reason for surgery was cosmetic disfigurement in 66 (95%) patients. The original Nuss technique was used in 63 patients, whereas 7 patients required an additional sub-xiphoid approach. Time to implant removal ranged from 8 months to 3 years. Results The cosmetic outcome was considered satisfactory by the patients in 64 (91%) cases and by the surgeon in 60 (85.7%) cases. Major complications requiring further surgery occurred in 6 (8.5%) patients and consisted of haemothorax (n = 2), chest wall sepsis (n = 2, including 1 after implant removal), allergy (n = 1), and implant displacement (n = 1). Early or delayed minor complications occurred in 46 (65%) patients and resolved either spontaneously or after non-surgical therapy. Discussion The minimal scarring and reliably good outcomes support the widespread use of the Nuss technique in children and adolescents. Our complication rates (minor, 65%; and major, 8.5%) are consistent with previous publications. In our opinion, contra-indications to thoracoscopic PE correction consist of a history of cardio-thoracic surgery and the finding by computed tomography of a sternum-to-spine distance of less than 5 cm or of sternum rotation greater than 35°. In these situations, we recommend a sub- and retro-xiphoid approach to guide implant insertion or a classic sterno-chondroplasty procedure. Level of evidence Level IV, retrospective descriptive cohort study.