Unusual locations of osteoarticular tuberculosis in children: a report of 12 cases.

INTRODUCTION: Unusual locations of osteoarticular tuberculosis (OA-TB) raise diagnostic issues due to their untypical and non-suggestive clinical and radiological presentation. OBJECTIVES: The present retrospective study analyzed the various clinical, radiological and therapeutic aspects. PATIENTS AND METHODS: A retrospective series included 12 children (mean age, 7 years 4 months; sex-ratio, 0.7), treated in our department between 1980 and 2010. Knee, hip and spine locations were excluded. RESULTS: Mean time to diagnosis was 32 months. Active TB infection was identified in 42% of cases. Pain was the presenting symptom in 83% of cases, with a preponderance of osteitis. Bone loss was the main radiological sign. Phemister's triad was found in two cases of combined articular and bone infection. Diagnosis was confirmed on histology in 92% of cases. All patients were managed according to the Moroccan national TB protocol. Surgery was indicated in five cases, comprising abscess drainage with or without bone surgery (notably for joint dislocation). Four patients showed orthopedic sequelae, including two with associated spinal locations. DISCUSSION: Rare osteoarticular tuberculosis locations often cause diagnostic problems. Any chronic clinical presentation or suspected atypical bone lesion should suggest a diagnosis of osteoarticular tuberculosis. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Identification and quantification of microcystins from a Nostoc muscorum bloom occurring in Oukaïmeden River (High-Atlas mountains of Marrakech, Morocco).

Health risks generated by cyanobacterial toxins in drinking and recreational waters are clearly recognised. During the monitoring programme on the distribution of toxic freshwater cyanobacteria in various water bodies including reservoirs, ponds and rivers of Morocco, many toxigenic cyanobacteria bloom-forming species have been identified. Particular attention was given to the investigation of the toxicology of a benthic Nostoc species-Nostoc muscorum Ag. (cyanobacteria, Nostocales, Nostocaceae)-that was found dominant in Oukaïmeden river located at 2,600 m of altitude in High-Atlas mountains of Marrakech. The massive growth of the mat-forming N. muscorum occurred yearly during the period of March-October, when the water temperature was above 10 degrees C. During 1997-1999, samples were collected from either floating or benthic mats. Hepatotoxicity associated to gastrointestinal (diarrhoea) intoxication symptoms was confirmed by intraperitoneal (i.p.) injection in mice of N. muscorum thallus extract. The survival time was estimated to be from 2-5 h, and the calculated i.p. LD(50) in mice ranged from 15 to 125 mg kg(-1) body weight. The application of the high performance liquid chromatography with photodiode array detection confirmed the occurrence of microcystin-LR (MC-LR) and three others microcystin variants from the methanolic Nostoc extract. The MC-LR represented a proportion of 39% of the total microcystin content however, the total concentration equivalents-eq-of MC-LR was estimated to be 139 microg MC-LR eq per gram dry weight. The existence of a benthic microcystin-producing N. muscorum strain under the particular environmental conditions of Oukaïmeden region may be a potential human health hazard and the ecological harmful effects of these cyanobacterial toxins need to be assessed. This paper constitutes the first report of the occurrence of a toxic benthic Nostoc in Morocco. So, the benthic species should be considered during monitoring of toxic Cyanobacteria particularly for river used for source of drinking water.

[Medial epicondyle fractures in children]. / Les fractures de l'epicondyle médial chez l'enfant.

INTRODUCTION: Medial epicondylar fractures account for 11% of elbow injuries in children. It represents a Salter-Harris type I lesion. Diagnosis is difficult but on the whole, results are satisfactory. The treatment of this fracture is controversial. PATIENTS AND METHODS: Our study looked at fifty-nine patients between 7 and 14 years old. The main mechanism of injury in our study was a fall (98%). The significance of the fracture displacement was judged according to the classification of Marion and Faysse. We noted 10 cases of stage II, 14 cases of stage III and 35 cases of stage IV according to their classification. Forty-one patients were treated by surgical fixation. Fifty patients were reviewed at an average of six years follow up and the results evaluated according to the criteria of Hardacre. RESULTS: The result was good in 95% of those cases with conservative treatment and in 80% of those cases with operative treatment. Prominence of the medial epicondyle and limitation of elbow motion were the main complications. DISCUSSION: According the literature, a sports accident is the most frequent cause of the injury. The results are better with conservative treatment because there is no relation between fracture displacement and final results. The excellent results of conservative treatment permit us to recommend this method except in those cases with a persistent intra-articular fragment or neurovascular complication.

[Aneurismal bone cyst in children: 17 cases]. / Le kyste osseux anévrysmal chez l'enfant: à propos de 17 cas.

INTRODUCTION: The aneurismal bone cyst (KOA) represents 1.5 to 4% of benign osseous tumors. It affects the young patients and its etiopathogeny is still discussed. Numerous difficulties of diagnostic, therapeutic and specially evolution, characterize this pathology. MATERIAL AND METHODS: Our study reports 17 patients who were treated between 1976 and 2000. The average age was 8 years and delay of diagnostic was 11 months. It affected the long bones in 70%, the brief bones in 25% and the flat bones in 5%. In limbs, the pathological fracture was revealing in 47%, the painful lameness in 35% and tumefaction in 18% of cases. For two vertebral locations, pain was associated with a stiff neck for the cervical spine and there was a deformation with a medullar compression for the lumbar vertebral location. The radiological aspect was typical in 82% of cases. First biopsy in 13 cases allowed to confirm the KOA in eight cases; for five cases, a second biopsy was necessary to confirm diagnosis. In four cases, diagnosis was hold on typical radiographic aspect or on the hemorrhagic nature of the cyst. The surgery was realized in 15 cases (88%), with 13 eventrations and graft (three osteosynthesis) and two complete exeresis. The radiotherapy was performed for a hemorrhagic cyst located in cervical spine. Finally, a cast immobilization alone was realized for a location of the patella. RESULTS: A good result was observed in nine cases, the recurrence in three cases, degeneracy in one case and we deplore one death following a toxic shock. Degeneracy seems to be due to an initial misunderstanding of the osteosarcoma. Three patients could not be evaluated for the study. DISCUSSION: The KOA is a solitary bone dystrophy that can be primitive, or secondary to a sometimes-sly underlying hurt. The symptomatology is varied according to the location; modern imaging allows to better defining of the KOA aspects. Biopsy is indispensable for the diagnosis, but histological confirmation is not always certain. The best treatment must permit the "carcinologic" removal of the KOA. The reconstruction will be done by graft and osteosynthesis if necessary. The injection of ethibloc and the embolisation are indicated for the voluminous and very aggressive cysts. Radiotherapy, with its important morbidity, can be used for the inoperable cases. Unpredictable evolution remains threatened by the risk of local recurrence and later, by the risk of degeneracy.

[Vertebral hydatidosis: three case reports]. / Hydatidose vertébrale: à propos de trois cas.

PURPOSE OF THE STUDY: Vertebral hydatidosis, the most frequent localization of skeletal hydatidosis, has an ominous prognosis with the risk of progressive but permanent neurological damage. There is no consensus on appropriate management. Treatment is often unsuccessful with frequent recurrence. The purpose of this study was to assess our experience with this rare disease to identify diagnostic, therapeutic and prognostic features. MATERIAL AND METHODS: We reviewed the charts of three patients with vertebral hydatidosis treated at the department of orthopedics at the Casablanca children's hospital between January 1989 and January 1998. Diagnosis was made early in the first patients, allowing complete excision of the hydatid cyst. Follow-up was uneventful 10 years after surgery. The second patient presented after a long disease course and had definitive neurological complications despite treatment. The lesions were extensive in the third patient and cure could not be achieved although the patient remained asymptomatic. DISCUSSION: Vertebral hydatidosis is a severe disease causing frequent neurological complications. Surgical treatment, though difficult, is the only efficient option. Complete recovery can be achieved after surgical excision of lesions diagnosed early. Prevention is the best therapeutic strategy in endemic areas.

[Aneurysmal cyst of the pelvis. Apropos of a case]. / Kyste anévrysmal du bassin. A propos d'un cas.

The authors present an aneurysmal bone cyst of the pelvis which was unusual in its radiographic aspects. Its aggressive features made it difficult to distinguish from a malignant lesion. We develop the imaging methods contribution in positive and differential diagnosis and underline the modern methods interest (CT scan, MR imaging). Biopsy is necessary to confirm the diagnosis and recognize possible causal malignant tumor.

[Neonatal treatment of congenital hip dislocation using an abduction pillow]. / Traitement néo-natal de la luxation congénitale de hanche par coussin d'abduction.

Numerous and various devices are being used in the treatment of congenital dislocation of the hip before the age of 1 year. We prefer the abduction pillow of Becker, owing to the simple design and use; there is also an economical factor: everybody can afford it. The abduction pillow can in no way be used for prevention. Only pathological hips with clinical signs confirmed by X-ray or sonography justify this treatment. Because of the good tolerance and efficacity of the pillow, it is the first choice treatment for unstable and luxated hips before the age of 4 months. If hips are not centered, other procedures should be used, in particular the Pavlik harness.

[Treatment of the dislocated hip in older children]. / Traitement de la hanche luxée chez le grand enfant.

Between 1976 and 1987, 85 cases of CDH occurring after walking age were followed in the department. Eighteen children aged 5 years or older were reviewed. In 11 children the dislocation was unilateral and in 7 bilateral; out of these 25 hips, 20 were high luxations and 5 occurred at a lower level. Two children, 6 and 13 years old, had a bilateral dislocation. Except for 2 children of 5 years of age who were treated conservatively, surgical treatment was indicated in the other 18 cases usually after tenotomy and derotation. In 13 hips, a surgical repositioning was performed, associated with femoral osteotomies, either shortening osteotomies (7) or derotation osteotomies (3). Pelvic osteotomies were indicated either immediately or later in 15 hips. A triple osteotomy was usually performed (11); a Salter (2) or a Chiari (2) has been rarely used. After a follow-up of 5 years, evaluation according to clinical and radiological criteria showed 14 good and 7 bad results. The latter 7 cases had either a dislocation or an eccentration. Reviewing these series, the authors describe the problems in the treatment of the dislocated hip in the older child: the indications, the therapeutic strategy for those dislocations and the decision for treatment of the bilateral high dislocation in the older child.

[Rectal prolapse in children. Review of 260 cases]. / Le prolapsus rectal de l'enfant. Revue de 260 cas.

Rectal prolapse is mostly seen in constipated children after prolonged straining at stool. In Morocco, it will occur in children suffering from digestive parasitosis or hypotrophic children following episodes of acute diarrhea. In order to evaluate the respective role of these factors and consequently adapt the management of this condition, a prospective study of 260 cases was conducted between 1979 and 1986 bearing on etiologic factors on the one hand and with a view to assessing the efficacy of medical treatment and of sclerosing injections on the other hand. As regards etiology, diarrhea in connection with digestive parasitosis appears as a predominating factor (62%). A deficient condition was also noted in 67 out of 160 children (42%). Medical treatment was successful only in 28% of cases, whereas 98% of our patients were cured by sclerosing injections without need for surgical treatment.

[The treatment of Pott's disease in children. Apropos of 100 cases]. / Le traitement du mal de pott de l'enfant. A propos de 100 cas.

Between 1976 and 1984, 100 children aged 13 months to 15 years were treated for tuberculosis of the spine. 29 patients seen at an early stage and presenting limited lesions healed completely with mild or moderate residual kyphosis after orthopaedic treatment associating antibiotherapy and strict immobilization in plaster shells. 71 patients having extensive vertebral destruction or after failure of the orthopaedic treatment underwent surgery for excision and anterior spine fusion. A supplementary posterior spine fusion was performed in 48 patients. This procedure, in conjunction with preoperative traction, obtained stabilization of the spine and healing of vertebral lesions in most cases with excellent correction of recent kyphosis. In view of these results, it seems possible to determine which treatment is best adapted according to: the extent, severity and level of the lesions, the degree and age of kyphosis, the existence or not of paraplegia. The possibility to reduce fixed severe kyphosis (6 cases) and the indication for a supplementary posterior fusion are evaluated.

[Atlanto-axial dislocations in children]. / Les dislocations atloïdo-axoïdiennes chez l'enfant.

A series of 9 cases of atlanto-axial dislocation observed between 1976 and 1982 illustrates the wide range of etiologic factors as well as their possible implication. The findings were as follows: 3 congenital anomalies of the odontoid process, 2 luxations resulting from trauma, 1 spine infection, 2 Grisel syndromes, 1 psoriatic rheumatism. Among them 3 children had incomplete tetraplegia. Six patients were treated by posterior spine fusion either directly or after failure of conservative management. The authors emphasize the difficulty in relating the disorder to its real cause and discuss the various methods of treatment according to the etiology, whether reduction and stabilization are possible and according to the neural involvement and the date of onset of the disorders.

[New approach to the management of caustic esophageal stricture in children (author's transl)]. / Une nouvelle thérapeutique des sténoses caustiques de l'oesophage chez l'enfant.

The management of long segment esophageal stenosis following chemical burns in children remains a difficult problem although various kinds of treatment have been proposed. The surgical treatment, consisting in replacing the injured segment, is mutilating and always performed at some risks. On the other hand dilatations must be carried on over several years in order to produce results and are not compatible with normal life. Furthermore, they are often followed by complications. The authors have been led to develop a method which would both allow the conservation of the esophagus and avoid long term dilations. This procedure mainly consists in a lengthwise myotomy of the residual structure after 12 or 18 months retrograde dilatations so as to peel off the wall fibrosis. The technique is presented and discussed about 2 successfully treated cases with a 9 to 12 months follow up.