Do teenagers return to normal physical activity levels after limb fractures? A longitudinal, accelerometry-based, activity monitoring study.

PURPOSE: This study aimed to elucidate whether levels of physical activity (PA) return to normal after bone healing or whether long-term behavioural changes in PA are to be expected in children and teenagers who have sustained limb fractures. METHODS: In all, 100 children and teenagers with a first episode of limb fracture and 100 sex- and age-matched healthy controls (CTRL) were recruited for a prospective study. PA in limb fracture patients was assessed at 18-month follow-up using accelerometer measurements, and values were compared with those of CTRL. Time spent in PA at different levels of intensity was determined for each participant and expressed in minutes and as a percentage of total validly measured time. RESULTS: Mean levels of PA at different levels of intensity by previously injured children and teenagers were similar than CTRL (42 sets of paired data). However, time spent in moderate-to-vigorous PA (MVPA) was lower than 60 minutes among limb-fracture patients at 18-month follow-up. CONCLUSION: The amount of skeletal loading in children and teenagers returns to normal values by 18 months after limb fracture. Even if time spent in MVPA is not significantly lower in children and teenagers with limb fractures, it no longer reached the international recommendations for school-aged children (MVPA > 60 minutes), which may be interpreted as a lifestyle modification or a behavioural change to avoid new trauma. LEVEL OF EVIDENCE: II.

Spinal infections in children: a multicentre retrospective study.

Aims: This multicentre, retrospective study aimed to improve our knowledge of primary pyogenic spinal infections in children by analyzing a large consecutive case series. Patients and Methods: The medical records of children with such an infection, treated at four tertiary institutions between 2004 and 2014, were analyzed retrospectively. Epidemiological, clinical, paraclinical, radiological, and microbiological data were evaluated. There were 103 children, of whom 79 (76.7%) were aged between six months and four years. Results: We confirmed a significant male predominance in the incidence of primary pyogenic spinal infections in children (65%). The lumbar spine was the most commonly affected region, and 27 infections (26.2%) occurred at L4/5. The white blood cell count was normal in 61 children (59%), and the CRP level was normal in 43 (42%). Blood cultures were performed in 95 children, and were positive in eight (8%). A total of 20 children underwent culture of biopsy or aspiration material, which was positive in eight (40%). Methicillin-sensitive Staphylococcus aureus (MSSA) and Kingella ( K.) kingae were the most frequently isolated pathogens. Conclusion: MSSA remains the most frequently isolated pathogen in children with primary pyogenic infection of the spine, but K. kingae should be considered as an important pathogen in children aged between six months and four years. Therefore, an empirical protocol for antibiotic treatment should be used, with consideration being made for the triphasic age distribution and specific bacteriological aetiology. In the near future, the results of polymerase chain reaction assay on throat swabs may allow the indirect identification of K. kingae spondylodiscitis in young children and thus aid early treatment. However, these preliminary results require validation by other prospective multicentre studies. Cite this article: Bone Joint J 2018;100-B:542-8.

Experimental study of progressive tibial lengthening in dogs using the Ilizarov technique. Comparison with and without associated intramedullary K-wires.

UNLABELLED: A delay in the union of bone regenerate in surgical lengthening procedures and the healing index (HI) are major factors in the quality of the results in progressive bone lengthening. Early removal of the external fixator (EF) is associated with a low rate of postoperative complications, including pin track infection, and with better muscle and joint function recovery. Addition of intramedullary wires (IMWs) to the EF led to a 9-49% decrease in the HI depending on the clinical series. We hypothesized that IMWs may accelerate the ossification process of bone regenerate and tested it in this experimental study. METHODS: Progressive tibial lengthening of 28 mm was obtained in 12 dogs operated with the classical Ilizarov technique (group I) and in 12 dogs operated with the same technique and addition of two IMWs 1.5 mm in diameter (group II). The following criteria were assessed: HI, X-ray measurements, and histological aspect of the bone regenerate and postoperative complications. RESULTS: The mean HI was 32.3% lower in group II than in group I. The radiological bone union criteria were observed on day 15 of the fixation period in group II versus day 30 in group I. Histology showed that maturation occurred earlier and bone cortices were thicker in group II than group I. Intramedullary ossification was present along the IMW in group II, whereas it was absent in group I. No clinical complications were observed in either group. DISCUSSION: The presence of the IMWs clearly contributes to stimulation of the ossification processes of the bone regenerate and to acceleration of bone union. IMWs allowed an earlier removal of the external fixator for a 32% time reduction compared to cases without IMWs. In addition, new intramedullary bone formation and presence of IMWs are expected to increase the mechanical resistance of the bone regenerate. CONCLUSION: Improvement of quantitative and qualitative criteria of bone regenerate in progressive bone lengthening with an EF combined with IMWs was demonstrated in this experimental study. SIGNIFICANCE: Favorable results encourage the authors to continue using IMWs in addition to the EF in patients treated with long-bone progressive lengthening. LEVEL OF EVIDENCE: II.

Occupational and patient exposure as well as image quality for full spine examinations with the EOS imaging system.

PURPOSE: EOS (EOS imaging S.A, Paris, France) is an x-ray imaging system that uses slot-scanning technology in order to optimize the trade-off between image quality and dose. The goal of this study was to characterize the EOS system in terms of occupational exposure, organ doses to patients as well as image quality for full spine examinations. METHODS: Occupational exposure was determined by measuring the ambient dose equivalents in the radiological room during a standard full spine examination. The patient dosimetry was performed using anthropomorphic phantoms representing an adolescent and a five-year-old child. The organ doses were measured with thermoluminescent detectors and then used to calculate effective doses. Patient exposure with EOS was then compared to dose levels reported for conventional radiological systems. Image quality was assessed in terms of spatial resolution and different noise contributions to evaluate the detector's performances of the system. The spatial-frequency signal transfer efficiency of the imaging system was quantified by the detective quantum efficiency (DQE). RESULTS: The use of a protective apron when the medical staff or parents have to stand near to the cubicle in the radiological room is recommended. The estimated effective dose to patients undergoing a full spine examination with the EOS system was 290 µSv for an adult and 200 µSv for a child. MTF and NPS are nonisotropic, with higher values in the scanning direction; they are in addition energy-dependent, but scanning speed independent. The system was shown to be quantum-limited, with a maximum DQE of 13%. The relevance of the DQE for slot-scanning system has been addressed. CONCLUSIONS: As a summary, the estimated effective dose was 290 µSv for an adult; the image quality remains comparable to conventional systems.

Benign fibrous histiocytoma of bone in a paediatric population: a report of 6 cases.

Case records and radiological investigations of six children with benign fibrous histiocytoma were studied retrospectively. BFH occurred in the femur (n = 2), tibia (n = 2) and fibula (n = 2). Clinically, patients reported pain from the lesion lasting several months (mean 6 months). The pain was not associated with pathological fracture in any patient. On X-rays, the lesions appeared as lytic and sharply demarcated with a sclerotic rim and fine trabeculations. The reported cases were located in the metaphysis and the diaphysis of the long bones. The tumour was restricted to bone, without periosteal or soft tissue reaction. Treatment consisted of careful intralesional curettage of the lesion; the defect was thereafter filled with bone bank graft or injectable phosphocalcic cement. The length of follow-up ranged from 24 months to 4.75 years (mean 35.2 months). One case presented with recurrence of the disease and required successful repeat intralesional curettage. Benign fibrous histiocytoma is probably underestimated among patients less than 20 years of age. This diagnosis should be considered in any child or teenager who presents with a non-ossifying fibroma accompanied by unexplainable pain or a rapid growing. Surgery restricted to the osteolytic lesion seems sufficient to achieve bone healing.

[Pediatric osteo-articular infections with negative culture results: what about Kingella kingae?]. / Infections ostéo-articulaires septiques à culture négative chez l'enfant: avez-vous pensé à Kingella kingae?

Kingella kingae is an emerging pathogen that is recognized as a causative agent of septic arthritis and osteomyelitis, primarily in infants and children. The bacterium is best detected by rapid inoculation in blood culture systems or by real-time PCR assays. Pathogenesis of the agent was linked recently to the production of a potent cytotoxin, known as RTX, which is toxic to a variety of human cell types. The locus encoding the RTX toxin is thought to be a putative virulence factor, and is, apparently, essential for inducing cytotoxic effects on respiratory epithelial, synovial and macrophage-like cells. Herein, we describe a novel real-time PCR assay that targets the RTX toxin gene. The assay exhibited a sensitivity of 30 c.f.u., which is 10-fold more sensitive than a previously published semi-nested broad-range 16S rRNA gene PCR, and showed no crossreactivity with several related species and common osteoarticular pathogens. Its clinical impact is illustrated by three pediatric cases.

Pediatric leukemia revealed by a limping episode: a report of four cases.

Acute limping in children is a common reason for consultation in pediatric emergency units. Acute leukemia is a rarely encountered disease in the orthopedic surgeon's activity. In addition, its clinical presentation is not typical and therefore is a source of possible diagnostic delay. For such reasons, there is a definite risk of undiagnosing the actual etiology of the limping episode. We report our experience with four cases of children initially seen in the pediatric emergency department for limping, as their revealing presentation of acute leukemia. The limb pain was highly variable. The radiographic work-up was always normal. Peripheral blood abnormalities were initially absent in one case and blastic cells were absent in two cases. The physician in charge should remember that paraclinical work-up normal results do not exclude a diagnosis of acute leukemia, that any drop in hematopoietic cell counts should call for a myelogram and that paraclinical exams, including the hemogram, should be repeated until a diagnosis and improvement or confirmed cure is achieved over time.

Articular nodular fasciitis in the glenohumeral joint.

We describe a case of multiple intra-articular masses in the glenohumeral joint of a 15-year-old patient. The patient was treated with arthroscopic excision of the masses and synovectomy. Histological and immunohistochemical studies were consistent with those of a nodular fasciitis. Follow-up examination did not reveal recurrence at 6 months. In this article we report the first case of articular nodular fasciitis in the glenohumeral joint with unusual imaging findings.

[The Legg-Calvé-Perthes disease: which assessment? Which therapeutic approach?]. / L'ostéochondrite primitive de to hanche ou maladie de Legg- Calvé-Perthes: quel bitan ? quelle prise en charge?

Legg-Calvé-Perthes disease remains indefinite from an etiologic point of view and unforeseable in its evolution. The evolution depends on the extent of epiphyseal involvement and the age of the child. It may safely be stated that the more extensive the epiphyseal involvement, the more compromised is the prognosis. Also the older the child, the more the femoral head remoulding will be limited. Preserving articular mobility and containing the head within the depth of acetabulum constitute the mainstay of treatment aiming for a femoral head as spherical as possible upon completion of growth. At the end of growth spherical or ovoid heads will cause no or few problems, however strongly deformed femoral heads will evolve into early hip arthritis. The early recognition of which hip will profit from which treatment, constitutes the major difficulty of the therapeutic process.

[Sciatic lesions associated with hip surgery]. / Lésions du nerf sciatique en chirurgie de la hanche.

PURPOSE OF THE STUDY: The incidence of neurological lesions after hip surgery is underestimated because of variable clinical expression and functional disorders resulting from nerve injury and often considered to be the normal course after hip surgery. The incidence of nerve lesions after hip surgery for fractures of the proximal femur remains to be detailed. MATERIAL AND METHOD: This retrospective study included 20 cases of sciatic nerve injury following hip surgery (2554 THA, 394 revision THA, 4632 osteosyntheses or hemiarthroplasties of the proximal femur). We noted degree of recovery of the neurological deficit and deterioration of the patients' quality-of-life. The prognosis was determined on the basis of clinical and electromyographic data. RESULTS: The incidence of nerve injury after hip surgery was 0.5% after THA, 1% after revision THA, and 0.08% after osteosynthesis or hemiarthroplasty of the proximal femur. The etiological factor remained unknown in the majority of the cases. The prognosis was tightly related to the type of neurological lesion as defined by the electrophysiological study. Three revision procedures were performed: two for drainage of a compressive hematoma and one to release the sciatic nerve (neurolysis). The prognosis depended on the type of neurological lesion as established by the electroneuromyographic study. DISCUSSION: Severe axonotmesis is associated with late recovery, generally incomplete recovery, and poor long-term functional outcome.

Gorham-Stout disease of costo-vertebral localization: radiographic, scintigraphic, computed tomography, and magnetic resonance imaging findings.

Gorham-Stout disease is a clinical, radiographic, and histological entity characterized by progressive osteolysis as a result of a histologically benign vascular proliferation involving bone. We present a case involving the cervical and thoracic spine and the osseous thorax, with attention to the clinical, radiographic, scintigraphic, computed tomography, and magnetic resonance imaging findings. These subjects are discussed in the light of the literature.

Pediatric seatbelt injuries: unusual Chance's fracture associated with intra-abdominal lesions in a child.

The authors report the case of a 7-year-old child involved in a motor vehicle accident. She sustained an unusual flexion-distraction vertebral injury. This spinal injury was related to seatbelt use and was associated with intra-abdominal lesions. The spinal lesion consisted of a posterior ligamentous disruption with widening of the posterior intervertebral space at two adjacent lumbar levels. The purpose of this case report is to describe an atypical and perhaps often unrecognized spinal lesion and to explain our approach to diagnosis and treatment.

[Acute bone and joint infections in children: how much attention should be paid to persistent fever during intravenous antibiotic therapy?]. / Infections ostéo-articulaires aiguës de l'enfant et fièvre persistante: la temérature est-elle un critère d'efficacité de l'antibiothérapie.

PURPOSE OF THE STUDY: Bone and joint infections are challenging therapeutic situations requiring rapid antibiotic therapy as soon as bacteriology specimens have been obtained. Laboratory tests (C reactive protein, erythrocyte sedimentation rate, white cell count) and clinical findings are used to assess therapeutic efficacy. Most of the clinical signs however, particularly in children or after a surgical procedure, are not explicit enough to allow proper assessment of the clinical course under antibiotic therapy. Body temperature is the only parameter currently used in routine practice. But the measurement of body temperature is not always reliable and variations observed during treatment should not always be attributed to treatment failure. The purpose of this work was to assess the significance of changes in body temperature observed in children given effective intravenous antibiotic treatment for bone and joint infections. MATERIAL AND METHODS: We reviewed retrospectively the files of 60 children treated in our unit for acute bone and joint infections. The patients had acute hematogeneous osteomyelitis (n=27), septic arthritis (n=25), and infectious osteoarthritis (n=8). A bacterial strain was identified on cultures of blood, joint fluid, or metaphysis puncture samples in all cases. Blood test results (C-reactive protein, erythrocyte sedimentation rate, white cell count) were recorded during treatment. Body temperature was recorded three times a day until normalization then daily until discharge. We searched for correlations between variations in the temperature curve observed during treatment and blood test results. RESULTS: Ninety percent of the children had fever at admission (mean 39.1 degrees C). Among the six children without fever, the temperature rose in 5 during the first 48 hours of hospitalization. Even when the treatment was effective, apyrexia was achieved slowly, on the average after 8 days of antibiotic treatment. We also observed that the peak temperature occurred during the first 5 days of antibiotic treatment considered effective. C-reactive protein level normalized within a satisfactory time (10.5 days), reflecting the efficacy of the antibiotics. DISCUSSION: The efficacy of antibiotic treatment must always be verified in patients with acute bone and joint infections. Generally, biological parameters are used to monitor efficacy. Currently, C-reactive protein appears to be the most reliable parameter to assess efficacy, its rapid decline reflecting clinical cure. Erythrocyte sedimentation rate and white cell counts are poor surveillance parameters. Finally, body temperature is not a specific surveillance parameter and persistent fever during treatment does not necessarily signify ineffective antibiotic treatment. In light of this fact, body temperature should always be compared with C-reactive protein level to draw any conclusion concerning therapeutic failure.

An unusual Monteggia type-I equivalent fracture in a child.

A six-year-old girl sustained a Monteggia type-I equivalent fracture of the right forearm. We describe the method of treatment of this rare fracture and its outcome.

Corrective surgery for idiopathic scoliosis after heart transplantation.

Cardiac transplant surgery is being performed with increasing frequency as a treatment for end-stage heart disease. In addition to the well-known post-surgical problems of rejection and infection, these patients may present at a future date with other medical problems which require surgical treatment, including orthopaedic pathology. Severe idiopathic scoliosis has been described in association with congenital heart disease, and its surgical treatment poses considerable risks because of heart disease. Spinal fusion in heart transplant recipients involves similar risks due to the particular physiology and pharmacological reactions of the denervated heart. Several cases of cholecystectomy performed in heart transplant recipients have been described, but to our knowledge no orthopaedic procedures have been reported in such patients. We report on a 15-year-old patient who underwent successful corrective surgery for idiopathic scoliosis 14 months after heart transplant.

[Knee arthroscopy in children]. / Arthroscopie du genou de l'enfant.

PURPOSE OF THE STUDY: Between 1990 and 1998, 110 knee arthroscopies were performed in children. We analyzed the epidemiology and diagnostic data and studied the correlation between clinical and radiographic findings and the final diagnosis after arthroscopy in order to establish a consensus on use of knee arthroscopy in children. MATERIAL AND METHODS: We made a retrospective analysis of 110 knee arthroscopies performed in children, classing the patients in three age groups: 0-5 years, 5-10 years, 10-17 years. Clinical and radiological findings were compared with the arthroscopy findings. RESULTS: One or more arthroscopies were performed in 56 boys and 48 girls. Mean age at the time of the procedure was 12 years 4 months. There were 11 children aged 0-5 years, 14 aged 5-10 years and 85 aged 10-17 years. The main pathology was arthritis in the 0-5 year and 5-10 year age groups. Trauma was more frequent in the older children. Knee arthroscopy was found to be normal in 19 cases. DISCUSSION: For most surgery teams, arthroscopy is indicated for arthritis of the knee. Arthroscopy may also be needed for hemarthrosis. In these contexts, arthroscopy is both a diagnostic and therapeutic procedure. Our analysis demonstrates that emergency arthroscopy is only warranted for free floating osteochondral fractures and fractures of the tibial articular surfaces, with the exception of the tibial spines. Arthroscopy may be performed later in other cases after careful physical examination and radiographic series. We had 19 normal arthroscopies and 10 that showed femoropatellar chondropathies and plicas that could explain knee pain. We recommend arthrography before arthroscopy to avoid unnecessary procedures. CONCLUSION: Arthritis of the knee is an excellent indication for arthroscopy. Painful and acute hemarthrosis requires attentive physical exams and x-rays before making the decision for surgery.

[Fibrocartilaginous dysplasia and tibia vara in young children: presentation of 3 new cases with spontaneous resolution and review of the literature]. / Dysplasie fibrocartilagineuse focale et tibia vara unilatéral du jeune enfant: présentation de 3 nouveaux cas à résolution spontanée et revue de la littérature.

Focal fibrocartilaginous dysplasia is a rare and benign condition associated with unilateral tibia vara in toddlers. Three additional cases are reported in children aged 17, 18 and 26 months with spontaneous resolution. The authors discuss, based on a meta-analysis, the natural history of the disorder and review the diagnostic and pathophysiological problems. Since spontaneous remodeling of varus angulation and healing of the bony defect can be expected, biopsy and surgical intervention should be avoided.

Radiographic evaluation of anterior dislocation of the shoulder.

PURPOSE: To establish radiographic criteria to choose the most appropriate technique of reduction for each type of anterior glenohumeral dislocation, and to determine the type of dislocation which requires general anesthesia. MATERIAL AND METHODS: Radiography in two different projections was performed in 67 patients with antero-inferior shoulder dislocations before a reduction attempt. The method proposed by BOss-HOLZACH-MATTER was used as the primary technique for all shoulder dislocations. RESULTS: Most subcoracoid dislocations (84.4%) could be reduced by the BOss-HOLZACH-MATTER method while only a few subglenoid dislocations (15.8%) were reducible by this technique. Displaced associated fractures significantly reduced the success rate of the reduction attempts. CONCLUSION: Anterior dislocations of the shoulder require different methods of reduction depending upon the type (sub-group) of dislocation. Reduction of subglenoid dislocations with associated greater tuberosity fracture should be performed under general anesthesia to avoid head-splitting fracture.

[Extension osteotomy of the long metacarpal bones. A therapeutic solution to repairing flexion defects. Apropos of 14 cases]. / L'ostéotomie d'extension des métacarpiens longs. Solution thérapeutique aux vices de consolidation en flexion. A propos de 14 cas.

Fourteen extension osteotomies were performed in 13 patients with angular metacarpal malunion. Surgery was indicated by the limitation of mobility, the reduction in gripping capacity, and pain following digitopalmar grasping movements. After surgery, the patients regained good articular mobility. However, in 60% of cases a teno-arthrolysis was required upon removal of consolidation hardware to restore digital function. The operation allowed pain relief in two-thirds of the patient population; in the remaining subjects, pain was experienced when making grasping movements. At the final examination, in the majority of cases gripping strength was similar to that of the contralateral hand. In conclusion, correction of angular malunion by extension osteotomy is a demanding procedure, and whenever possible should be avoided by a precise reduction of the metacarpal fracture during initial surgery. A fractured metacarpal with a palmar angulation of over 15 degrees should systematically be reduced and fixed if unstable.

Anteroinferior shoulder dislocation: an auto-reduction method without analgesia.

OBJECTIVES: To describe a new reduction method for anteroinferior shoulder dislocations. DESIGN: Retrospective for the first thirty patients; prospective for the remaining seventy patients. SETTING: University hospital. PATIENTS: One hundred patients with anteroinferior shoulder dislocations. INTERVENTIONS: X-rays in two different projections were taken. The patient then was asked to sit on a relatively hard surface. The wrists were protected. The patients's forearms were placed around the homolateral knee, which is flexed at 90 degrees. The head of the examination table was lowered, and the patient was asked to lean backward with his or her neck in hyperextension. The patient had to push his or her shoulders (shrug) anteriorly, thus creating a rational movement of the scapula around a vertical axis. MAIN OUTCOME MEASURES: The authors analyzed initial prereduction x-rays and established a classification system based on the position of the humeral head, then assessed the success rate of the new technique with respect to the radiologic study. RESULTS: When using the reduction method described by Boss-Holzach-Matter, the authors attained an overall success rate of 60 percent, with a mean reduction time of three minutes and a time interval varying from fifteen seconds to nine minutes. CONCLUSION: The Boss-Holzach-Matter method is a reduction technique for anteroinferior shoulder dislocations that can be used without premedication or anesthesia. The authors recommend it for those patients who are not going to be sedated and for whom "quick" reduction and early discharge is desirable.