[Influence of age, growth potential and functionality in the management of bone tumours in children : example of the rotationplasty]. / Cas clinique. Influence de l'âge, du potentiel de croissance et de la fonctionnalité dans la prise en charge des tumeurs osseuses de l'enfant : exemple de la plastie de rotation.

Malignant bone tumours in children are rare diseases whose survival rate has progressively improved in recent years thanks to advances in pharmacology, surgery and radiotherapy. We present the particular case of a very young child with Ewing's sarcoma of the thigh. We discuss the influence of this young age on short and long term care. Limb skeletal immaturity and the residual growth potential need to be integrated to define the safest oncological and functional strategy. For this purpose, we summarize the different possible reconstructive options. We describe the Van Nes rotationplasty that was proposed in our patient's case and we will detail the issues in terms of functional well-being and self-image.

Les tumeurs malignes osseuses de l'enfant sont des pathologies rares dont la survie s'est progressivement améliorée au cours des dernières années grâce aux progrès médicamenteux, chirurgicaux et radiothérapeutiques. Nous présentons le cas particulier d'une très jeune enfant atteinte d'un sarcome d'Ewing de la cuisse. Nous discutons de l'influence de ce jeune âge sur la prise en charge à court et à long termes. L'immaturité squelettique et le potentiel de croissance résiduelle des membres doivent être intégrés pour définir l'attitude la plus sûre sur le plan oncologique et la plus fonctionnelle. à cette fin, nous résumons les différentes options reconstructives possibles. Nous décrivons la plastie de rotation de Van Nes qui a été proposée à notre patiente et nous détaillerons les enjeux relatifs au bien-être fonctionnel et à l'image de soi.

Aneurysmal bone cystic lesions: value of genomic studies.

Aneurysmal bone cystic (ABC) lesions can be primary or secondary (to a trauma or a pre-existing benign or malignant tumour). Specific translocations of the USP6 gene are reported in about 70% of primary but never in secondary ABC lesions. We report two cases of ABC lesions in which imbalanced genomic aberrations were detected at initial presentation and showed complex clonal evolution. These demonstrative observations strengthen the guidelines regarding the diagnostic approach when an ABC is suggested by imaging. Biopsy is mandatory including genomic analysis. When a primary ABC is not clearly proven by the initial biopsy, an extensive curettage should be performed, with pathological examination of all removed tissue in order to exclude a secondary ABC. It also illustrates the added value of genomic analyses in the setting of an ABC lesion: complex clonal aberrations argues for a lesion secondary to a malignant proliferation whereas USP6 rearrangement allows the diagnosis of primary ABC.

Risk factors for additional surgery after closed reduction of hip developmental dislocation.

PURPOSE: to evaluate the risk factors for additional surgery after closed reduction of hip developmental dislocation Methods : closed reduction for developmental hip dislocation was performed on 72 patients, with a total of 82 hips (10 bilateral). Were included only patients with irreducible hip dislocation who were treated by overhead traction followed by closed reduction under general anaesthesia and spica casting. The mean age at the time of closed reduction was 10 months, with 82% of dislocation diagnosed after the age of 6 months. In 28 hips (34.1%), no additional surgical procedure was necessary, while 54 hips (65.9%) needed an additional surgery, consisting in Salter osteotomy in 40 hips (48.8%) or open hip reduction in 14 (17.1%). RESULTS: risk factors for the need of additional surgery were: older age at the time of reduction, male sex, high grade of hip dislocation (Tönnis grade 3 and 4, versus grade 1 and 2), and quality of hip reduction. All the patients older than 17 months at the time of closed reduction needed additional surgery. Bilateral hip dislocation had poorer Severin grading than unilateral dislocation. Poorer Kalamchi scoring was associated with older age and with the presence of the cephalic nucleus at the time of reduction. CONCLUSION: this study confirmed delayed diagnosis of hip dislocation leads to a more extensive treatment with poorer issue.

Complications associated with bone lengthening of the lower limb by callotasis.

The present study aims to assess the incidence of complications related to bone lengthening procedures and to identify factors that may predict these complications. We retrospectively studied 51 lengthening procedures in 39 patients (mean age 13 years) from 2001 to 2015. A circular external fixator was used in 37 procedures and a monolateral fixator in 14 procedures. Duration of distraction, fixator's time, days of treatment, lengthening percentage, bone healing index, distraction regenerate length, distraction index, risk factors and complications were evaluated. The mean follow-up was 5 years. Complications occurred in 84 % of the procedures. Duration of distraction, fixator's time, days of treatment and distraction regenerate length were predictors of complications. Close follow-up is necessary during distraction and healing period and after fixator removal.

Prevention of re-fractures of both bones of the forearm in children.

PURPOSE: The aim of this study was to observe if the re-fracture rate after forearm both bones was decreased by protecting the forearm with a preventive brace for 6 months following the fracture and by ceasing all physical activities. METHODS: We performed a retrospective study in 75 consecutive cases of diaphyseal fracture of both bone of forearms, in 52 boys and 23 girls aged from 6 months to 11 years. It concerned a first episode of fracture in 84% of cases and a re-fracture in 17%. RESULTS: Re-fracture rate was 0% in the group where a protective brace was worn while it was 20% in the group without brace. CONCLUSIONS: Both the wearing of a protective brace and absence of sport for 6 months may decrease the re-fracture rate to 0%, if the patient is compliant by wearing it and by ceasing all physical activities.

Patient-specific instruments for surgical resection of painful tarsal coalition in adolescents.

INTRODUCTION: Congenital tarsal coalition resection in adolescents may be hindered by the complex three-dimensional anatomy of the talocalcaneal joint. Peroperative fluoroscopy is not greatly contributive, especially for talocalcaneal coalition. HYPOTHESIS: 3D planning and patient-specific instruments facilitate the procedure. MATERIALS AND METHODS: A made-to-measure surgical guide (patient-specific instrument) was used in 9 consecutive patients for tarsal coalition resection (7 talocalcaneal and 2 calcaneonavicular coalitions). The guide was created by 3D modeling from the CT scan of the foot. Placed on the bone surface, it oriented the saw blade to resect the bone bridge at the appropriate depth. A fascia lata allograft was interposed. Complete resection and absence of recurrence were checked on postoperative CT in talocalcaneal and on radiography in calcaneonavicular coalitions. RESULTS: Resection was complete in all cases, with no recurrence at last follow-up. DISCUSSION: This technique makes tarsal coalition resection easier and more reliable and may be recommended to improve precision. LEVEL OF EVIDENCE: Level IV, prospective study of a new surgical technique.

Reliability of the Lagrange and Rigault classification system of supracondylar humerus extension fractures in children.

INTRODUCTION: The Lagrange and Rigault classification was designed to describe extension-type supracondylar fractures of the humerus. It can also help in treatment decision-making. HYPOTHESIS: The reliability of this classification has not yet been proven. The goal of this study was to assess this system's intra- and interobserver reliability. METHODS: One hundred supracondylar fracture radiographs were randomly retrieved and reviewed by five different observers on two occasions in a different order. The kappa index was used to calculate the intra- and interobserver reliability. RESULTS: Intraobserver reliability was 0.76 and interobserver reliability was 0.69. DISCUSSION: The study shows good intra- and interobserver reliability. The Lagrange and Rigault classification has similar reliability to other supracondylar fracture classifications.

Registration accuracy in computer-assisted pelvic surgery.

INTRODUCTION: An in vitro study was performed to assess the global registration accuracy of a computer-assisted system in pelvic orthopaedic surgery. The system was applied to a putative tumor resection in a pelvic sawbone. METHODS: Twenty landmarks were created on the surface of the pelvis, and a virtual model of the sawbone was constructed based on surface extraction from computed tomography. The coordinates of the landmarks were defined in the CT-scan coordinate system, and registration of the sawbone with the virtual model was achieved using a surface-based matching algorithm. The landmarks were considered as control points, and deviations between their physical locations and their locations in the virtual model were calculated, thereby quantifying the global accuracy error. RESULTS: The location of the initialization points was unimportant. The dynamic reference base gave the best results when placed far from the working area. Accuracy was improved when the sampling area was increased, but was decreased by its excessive expansion. CONCLUSIONS: It is recommended that the DRB be located on the contralateral side of the pelvis. Extending the approach posteriorly and including the entire working area in the sampling surface area, if possible, will also help increase accuracy in computer-assisted pelvic surgery.

[Results at skeletal maturity after double-approach hemivertebral resection]. / Résultats à maturité osseuse après résection d'hémivertèbres par double abord.

PURPOSE OF THE STUDY: The natural history of congenital scoliosis or kypho-scoliosis resulting from a hemivertebra is well documented. The spinal deformation generally worsens in children with a free or semi-segmented hemivertebra situated in the thoraco-lumbar, lumbar or lumbosacral region. MATERIAL AND METHODS: From 1982 to 1997, fifteen pediatric patients with 15 hemivertebrae causing progressive scoliosis or kypho-scolisosis underwent hemivertebral resection via a double posterior and anterior approach associated with convex fusion. Mean age at surgery was 4.4 years. The fifteen patients were reviewed at bone maturity (Risser 4 or 5) to assess outcome. RESULTS: Genitourinary tract anomalies were associated in five of the 15 patients and intrathecal anomalies in two. Mean follow-up was 12.1 years. Segmental scoliosis was 30.2 degrees preoperatively, 12.3 degrees postoperatively and 8.9 degrees at last follow-up. The values for total scoliosis were 30.5 degrees, 12.3 degrees and 12.6 degrees respectively. This was a 70.5% improvement at last follow-up for segmental scoliosis and 58.7% for total scoliosis. The real trunk imbalance improved from 31% preoperatively to 9% at last follow-up. All these differences were significant. DISCUSSION: The main objective of surgical treatment for congenital scoliosis due to hemivertebra is to prevent the development of severe deformation which would necessitate a dangerous and difficult procedure to achieve correction. Resection of the hemivertebra via a double approach is the ideal method for early correction. The procedure not only corrects the spinal deformation but also prevents later deterioration. Correction should be performed as early as possible. The result is sustained over time if there is no other associated spinal anomaly. The procedure is safe and the technique well controlled in experimented hands. Patients need to wear a corset for only six months after resection of the hemivertebra.

[Intra-articular myxofibrosarcoma of the hip in a 10-year-old child]. / Myxofibrosarcome intra-articulaire de la hanche chez un enfant de 10 ans.

We report a case of intra-articular myxofibrosarcoma with acetabular involvement observed in a 10-Year-old boy. Myxofibrosarcoma is a frequent soft tIssue sarcoma usually observed in elderly subjects. It is extremely rare in children and has not been reported previously before the age of 22 Years. Myxofibrosarcoma is a specific type of soft tIssue tumor. Discussion continues concerning its relation with the myxoid variant of malignant fibrous histiocytoma. The myxoid matrix harbors fibroblastic cells with a curvilinear vessel configuration. Prognosis is good after complete resection and careful surveillance. Local recurrence may occur generally with progression of the tumor stage and risk of later metastasis. This is the first report of an intra-articular localization. We discuss the therapeutic options.

Complications associated with gamma nailing. A review of 439 cases.

We have retrospectively analysed 439 peritrochanteric hip fractures treated in our institution using the Gamma nail, with attention focused on complications. Intraoperative complications were observed in 15 patients (3.4%), consisting mainly of fractures (1.8%). Out of 323 fractures (73.6%) followed until radiographic bone healing (mean follow-up of 10 months), 261 (80.8%) healed without a problem. There were 62 postoperative complications (19.2%) with 37 patients (11.5%) requiring additional surgical procedure. The two most frequent major complications were cut out of the cephalic screw (7.1%) and diaphyseal fractures (3.1%). Other complications included fracture collapse more than 2 cm (1.5%), infection (0.9%), delayed union (0.9%) with one case of nail breakage (0.3%) and persistent pain in 20 patients (6.2%). All intraoperative fractures, nearly all cases of postoperative cut out of the lag screw and some postoperative diaphyseal fractures can be related to technical errors. Strict observance of the operative technique can decrease per- and postoperative complications.

Effect of freeze-drying and gamma irradiation on the mechanical properties of human cancellous bone.

Freeze-drying and gamma irradiation are commonly used for preservation and sterilization in bone banking. The cumulative effects of preparation and sterilization of cancellous graft material have not been adequately studied, despite the clinical importance of graft material in orthopaedic surgery. Taking benefit from the symmetry of the left and right femoral heads, the influence of lipid extraction followed by freeze-drying of a femoral head and a final 25-kGy gamma irradiation was determined, with the nonirradiated, nonprocessed counterpart as the control. Five hundred and fifty-six compression tests were performed (137 pairs for the first treatment and 141 pairs for the second). Mechanical tests were performed after 30 minutes of rehydration in saline solution. Freeze-dried femoral heads that had undergone lipid extraction experienced reductions of 18.9 and 20.2% in ultimate strength and stiffness, respectively. Unexpectedly, the work to failure did not decrease after this treatment. The addition of gamma irradiation resulted in a mean drop of 42.5% in ultimate strength. Stiffness of the processed bone was not modified by the final irradiation, with an insignificant drop of 24%, whereas work to failure was reduced by a mean of 71.8%. Freeze-dried bone was a bit less strong and stiff than its frozen control. Its work to failure was not reduced, due to more deformation in the nonlinear domain, and it was not brittle after 30 minutes of rehydration. Final irradiation of the freeze-dried bone weakened its mechanical resistance, namely by the loss of its capacity to absorb the energy (in a plastic way) and a subsequent greater brittleness.

Simple bone cysts treated with aspiration and a single bone marrow injection. A preliminary report.

The results of a single percutaneous aspiration and injection of marrow into active, simple bone cysts are reported in 8 cases. Slow regression of the cyst was consistently observed except in one lesion in the distal tibia. All the patients have been free of symptoms after this treatment after a mean follow up of 31 months. The evolution of the cysts was monitored by a cyst index, cyst diameter measurements and computer assisted densitometric image analysis of serial radiographs.