Results of central ray metacarpal resection after failure of digit replantation in children.

Central ray amputation results severe esthetic blemish and functional and psychological sequelae. Three main reconstruction procedures have been reported in adults: digital translocation, intracarpal osteotomy, and metacarpal resection; none of these, however, have been studied in children. The aim of this study was to report medium-term results for treatment of central ray amputation by proximal metacarpal resection following failure of digit replantation in children (i.e., skeletally immature patients). All children consecutively operated on by metacarpal resection after failure of digit replantation for complete central ray amputation between 2012 and December 2017 were retrospectively included. The surgical procedure consisted in metacarpal resection through a palmar approach, with deep transverse metacarpal ligament reconstruction. At last follow-up, adjacent finger range of motion, pain, rotational deformity and grip strength were evaluated, as well as metacarpal laxity. Metacarpal migration index and metacarpal divergence were measured on standard X-ray. Eleven children with a mean age of 11 ± 8 years were included. At mean 18 ± 3 months' follow-up, range of motion in adjacent digits was conserved in all cases, with no intermetacarpal laxity. Grip strength was 28% lower than for the contralateral side. Two patients showed rotational malalignment in extension, without functional impairment. In 4th ray amputation (n = 8), metacarpal migration index was decreased by 65% due to radial migration of the 5th metacarpal, but metacarpal divergence was conserved in all cases. Isolated metacarpal resection of the central ray for replantation failure is a reliable and safe procedure with good radiological and functional results in skeletally immature children.

Bivertebral autostable claws for the proximal fixation in thoracic adolescent idiopathic scoliosis surgery.

STUDY DESIGN: Retrospective monocentric study. OBJECTIVES: To report radiologic outcomes of a consecutive series of AIS patients, operated with a bivertebral autostable claw for the upper instrumentation over a 5-year period. The upper fixation represents the weakest part of long constructs because of local anatomy and the high pull-out forces. Various implants have been proposed, but proximal junctional failures (PJF) and shoulder imbalance still occur with variable incidence. The autostable claw is a new implant, safe, and low profile, combining the mechanical strength of hooks with the initial stability of pedicle screws. METHODS: All AIS patients operated between January 2010 and July 2015 for a Lenke 1 or 2 curve with the bivertebral autostable claw were included. A minimum 2-year follow-up was required. Full-spine biplanar stereoradiographs were performed preoperatively, within 8 weeks postoperative and at latest examination. Local and global sagittal and coronal parameters were analyzed and complications were reported. RESULTS: 237 patients (191 Lenke 1 and 46 Lenke 2) were included, with a mean follow-up of 4.1 ± 0.6 years. PJF occurred in 2 patients (0.8%), and radiologic PJKs were observed in 8.4% of the series. Shoulder balance was efficiently restored or maintained in 88.2%. CONCLUSIONS: The bivertebral autostable claw is a safe and robust alternative to pedicle screws for proximal fixation in AIS long constructs. Compression and/or distraction can be applied to level shoulders, and mechanical failures remain rare at 4-year follow-up. LEVEL OF EVIDENCE: IV.

Pulmonary Function After Convex Thoracoplasty in Adolescent Idiopathic Scoliosis Patients Treated by Posteromedial Translation.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To analyze the morbidity of thoracoplasty, and more specifically its effect on pulmonary function, after surgery with hybrid constructs using sublaminar bands in adolescent idiopathic scoliosis (AIS). BACKGROUND: Cosmetic concern is one of the main reasons to consider surgery in adolescent idiopathic scoliosis. Several studies have demonstrated significant improvement of self-image scores after thoracoplasty. However, consequences of thoracoplasty on pulmonary function (ie, pulmonary function tests [PFTs]) remain controversial. METHODS: After institutional review board approval, 96 consecutive AIS patients with thoracic curves (Lenke 1 and 2) were included between January 2014 and November 2015. All patients underwent low-dose stereoradiography with 3D reconstructions. Surgical procedure was the same in all patients: posterior correction using posteromedial translation technique with hybrid constructs (thoracic sublaminar bands and lumbar pedicle screws). Pulmonary function was explored with PFTs (forced vital capacity, forced expiratory volume in 1 second, and total lung capacity). Radiographic parameters and PFT results were compared between patients with and without thoracoplasty preoperatively and at two years postoperation. RESULTS: Mean age was 15 ± 2 years, and body mass index averaged 18.8 ± 2.6. Thirty-six patients (37.5%) underwent thoracoplasty. Both groups were comparable preoperatively regarding demographic data, radiographic parameters, and PFT results. No significant difference was found between groups regarding postoperative correction rates. At the two-year follow-up, PFT results were similar to the preoperative ones and no difference was observed between groups. However, pleural effusions were reported in 26 patients (72%) on chest radiographs. Only one pleural effusion due to thoracoplasty required drainage. CONCLUSION: Results of the current study demonstrated that thoracoplasty associated with posteromedial translation technique did not alter PFT results at two years postoperation. The morbidity of the procedure is limited, and it can therefore be considered in patients with high cosmetic demand and significant residual rib hump after main curve correction. However, hump height and pain evaluation would be interesting data in a prospective study. LEVEL OF EVIDENCE: Level IV.

Are postoperative standing radiographs relevant before hospital discharge in adolescent idiopathic scoliosis?

PURPOSE: Postoperative standing radiographs are usually performed before hospital discharge after AIS fusion. However, patients are often still painful and have not recovered yet their physiological balance. The aim of this study was therefore to evaluate the relevance of such early radiographs and more specifically investigate whether postoperative alignment could be analyzed. METHODS: All consecutive AIS patients operated between January 2015 and December 2015 were included. All patients underwent biplanar stereoradiographs before hospital discharge, at 4 months postoperative and at last follow-up. Fifteen parameters (eight coronal and seven sagittal), reflecting correction and spinal alignment were measured and compared. The incidence of implant misplacement, requiring or not surgical revision, was recorded. RESULTS: In total, 100 patients were included. A significant difference was found for 12 out of the 15 (80%) parameters between the first erect radiograph and the 4-month follow-up visit, including the CVA and the SVA, which are commonly used to assess postoperative alignment. Clavicle, UIV and LIV tilts also decreased significantly at 4 months postoperative. In opposition, no significant change occurred for the same parameters between the 4-month visit and latest follow-up. In nine patients, a pedicle screw was considered misplaced on the first radiograph, but all patients remained asymptomatic and no revision was performed. CONCLUSION: There is no need for additional immediate postoperative radiographs in AIS, if an intraoperative radiograph has already been taken. This finding could help reducing radiation exposure in immature patients and should be further studied in other etiologies. These slides can be retrieved under Electronic Supplementary Material.

Paediatric tibial shaft fractures treated by open reduction and stabilization with monolateral external fixation.

PURPOSE: Elastic stable intramedullary nailing is increasingly used for surgical treatment of tibial shaft fractures, but frequently requires immobilization and delayed full weight-bearing. Therefore, external fixation remains interesting. The aim was to report clinico-radiological outcomes of monolateral external fixation for displaced and unstable tibial shaft fractures in children. METHODS: All tibial fractures consecutively treated by monolateral external fixation between 2008 and 2013 were followed. Inclusion criteria included skeletal immaturity and closed and open Gustilo I fractures caused by a direct impact. Patients were seen until two years postoperatively. Demographics, mechanism of injury, surgical data and complications were recorded. Anteroposterior and lateral side radiographs were performed at each visit. Full-limb 3D reconstructions using biplanar stereroradiography was performed for final limb length and alignment measures. RESULTS: A total of 45 patients (mean age 9.7 years ± 0.5) were included. In all, 17 were Gustilo I fractures, with no difference between open and closed fractures for any data. Mean time to full weight bearing was 18.2 days ± 0.7. After 15 days, 39 patients returned to school. Hardware removal (mean time to union 15.6 weeks ± 0.8) was performed during consultation under analgesic gas. There were no cases of nonunion. No fracture healed with > 10° of angulation (mean 5.1° ± 0.4°). Leg-length discrepancy > 10 mm was found for six patients. CONCLUSIONS: This procedure can be a safe and simple surgical treatment for children with tibial shaft fractures. Few complications and early return to school were reported, with the limitations of non-comparative study. LEVEL OF EVIDENCE: IV.

Management of osteonecrosis of the femoral head in children with sickle cell disease: results of conservative and operative treatments at skeletal maturity.

PURPOSE: Sickle cell disease (SCD) is the most common cause of femoral head osteonecrosis (ONFH) during childhood with an overall prevalence of 10%. In children, spontaneous revascularization can occur, as in Legg-Calve-Perthes disease. Consequently, the aim of treatment is to restore proper hip containment to prevent joint arthritis. This is the first study reporting long-term results at skeletal maturity of non-operative and surgical treatments for ONFH in SCD children. METHODS: All children with ONFH due to SCD were retrospectively reviewed. At initial evaluation, extension of osteonecrosis was radiographically defined using Catterall, lateral pillar Herring and Ficat classifications. Subluxation of the femoral head with Reimers migration index > 30% required surgical treatment including femoral varus osteotomy and/or pelvic osteotomies. Conservative treatment including non-weight bearing and physiotherapy was performed in the remaining cases. Outcomes were assessed at skeletal maturity using the Harris Hip Score (HHS) and the Stulberg classification. Total hip arthroplasty and Stulberg 5 were defined as failures. RESULTS: A total of 25 hips in 17 patients were included (mean follow-up 7.5 years SD 3.4). Mean age at diagnosis was 11.4 years SD 2.9. In all, 15 hips (60%) were classified Catterall 3 and 4 and Herring B and C. A total of 13 patients (52%) underwent surgical treatment. At skeletal maturity, mean HHS was good (81 SD 17), 12 hips (48%) were classified Stulberg 1 and 2, seven hips (28%) were classified Stulberg 3 and 4. CONCLUSION: Both treatments led to good functional results with 75% of congruent hips at skeletal maturity. LEVEL OF EVIDENCE: IV.

Radiological and functional outcomes of high-grade spondylolisthesis treated by intrasacral fixation, dome resection and circumferential fusion: a retrospective series of 20 consecutive cases with a minimum of 2 years follow-up.

PURPOSE: Major concern during surgery for high-grade spondylolisthesis (HGS) is to reduce lumbosacral kyphosis and restore sagittal alignment. Despite the numerous methods described, lumbosacral fixation in HGS is a challenging technique associated with high complication rate. Few series have described outcomes and most of the results are limited to lumbosacral correction without global sagittal alignment analysis. This study aims at analyzing clinical and radiological outcomes of HGS patients treated with intrasacral rods on full spine radiographs. METHODS: HGS patients (Meyerding III or higher) operated between 2004 and 2014 were reviewed. All patients underwent full spine stereoradiographic images. After L5 and S1 decompression, reduction and circumferential fusion with intrasacral rod fixation and fusion up to L4 were performed under fluoroscopy. The entry points for S1 screws were located 3-5 mm above and 5 mm lateral to the first sacral hole, toward the promontory. The two short distal fusion rods were then positioned into the sacrum guided by anteroposterior fluoroscopy using Jackson's technique. Then, sacral dome resection was performed and a PEEK cage was impacted in L5S1 after reduction. Postoperatively, the hip and knee were kept flexed at 45° for 1 week and extended progressively. Preoperative, 3 months postoperative and last follow-up (> 2 years minimum) clinical and radiographic data were collected. Sagittal parameters included lumbosacral angle (LSA), olisthesis, T1 spinopelvic inclination (T1SPi) and spinopelvic parameters. RESULTS: 20 HGS patients were included (8 ptosis, 5 Meyerding IV). The mean age was 14 years. At final FU (7.2 years ± 3), LSA kyphosis and olisthesis were reduced (65° ± 14 vs 99° ± 11, p < 0.001 and 81% ± 19 vs 45% ± 18, p < 0.001, respectively). While L1L5 lordosis decreased, T1T12 kyphosis increased. At FU, global alignment with T1SPi was - 6° ± 3. No significant loss of correction was observed. Regarding complications, ten patients presented transient L5 motor deficit that occurred when patients were put in standing position. However, all recovered before 3 months postoperatively. CONCLUSION: Intrasacral rod fixation appears to be an effective technique to correct LSA kyphosis, compensatory hyperlordosis and restore global sagittal alignment with a postoperative T1SPi corresponding to the value of the asymptomatic subject and achieve fusion. However, it remains a demanding technique with high risk of transient neurologic complications.

Selective versus hyperselective posterior fusions in Lenke 5 adolescent idiopathic scoliosis: comparison of radiological and clinical outcomes.

PURPOSE: Recent literature has reported that the ]progression risk of Lenke 5 adolescent idiopathic scoliosis (AIS) during adulthood had been underestimated. Surgery is, therefore, proposed more to young patients with progressive curves. However, choice of the approach and fusion levels remains controversial. The aim of this study was to analyze the influence of the length of posterior fusion on clinical and radiological outcomes in Lenke 5 AIS. METHODS: All Lenke 5 AIS operated between 2008 and 2012 were included with a minimum 2-year follow-up. Patients were divided into two groups according to the length of fusion. In the first group (selective), the upper instrumented level (UIV) was the upper end vertebra of the main structural curve and distally the fusion was extended to the stable and neutral vertebra, according to Lenke's classification. In the second group (hyperselective), shorter fusions were performed and the number of levels fused depended on the location of the apex of the curve (at maximum, 2 levels above and below, according to Hall's criteria). Apart from the fusion level selection, the surgical procedure was similar in both groups. Radiological outcomes and SRS-22 scores were reported. RESULTS: 78 patients were included (35 selective and 43 hyperselective). The number of levels fused was significantly higher in the first group (7.8 ± 3 vs 4.3 ± 0.6). None of the patients was fused to L4 in selective group. No correlation was found between length of fusion and complication rate. Eight patients had adding-on phenomenon among which 6 (75%) had initially undergone hyperselective fusions and had significantly higher postoperative lower instrumented vertebra (LIV) tilt. In the adding-on group, LIV was located above the last touching vertebra (LTV) in 62.5% of the cases and above the stable vertebra (SV) in 87.5%. Patients in the selective group reported a significantly lower score in the SRS function domain. CONCLUSION: Coronal alignment was restored in both groups. Hyperselective posterior fusions can be considered in Lenke 5 AIS, preserving one or two mobile segments, with similar clinical and radiological outcomes. However, selection of the LIV according to SV and LTV need to be accurately analyzed in order to avoid adding-on during follow-up.

Titanium vs cobalt chromium: what is the best rod material to enhance adolescent idiopathic scoliosis correction with sublaminar bands?

PURPOSE: Cobalt chromium (CoCr) rods have recently gained popularity in adolescent idiopathic scoliosis (AIS) surgical treatment, replacing titanium (Ti) rods, with promising frontal correction rates in all-screw constructs. Posteromedial translation has been shown to emphasize thoracic sagittal correction, but the influence of rod material in this correction technique has never been investigated. The aim of this study was to compare the postoperative correction between Ti and CoCr rods for the treatment of thoracic AIS using posteromedial translation technique. METHODS: 70 patients operated for thoracic (Lenke 1 or 2) AIS, in 2 institutions, between 2010 and 2013, were included. All patients underwent posterior fusion with hybrid constructs using posteromedial translation technique. The only difference between groups in the surgical procedure was the rod material (Ti or CoCr rods). Radiological measurements were compared preoperatively, postoperatively and at last follow-up (minimum 2 years). RESULTS: Preoperatively, groups were similar in terms of coronal and sagittal parameters. Postoperatively, no significant difference was observed between Ti and CoCr regarding frontal corrections, even when the preoperative flexibility of the curves was taken into account (p = 0.13). CoCr rods allowed greater restoration of T4T12 thoracic kyphosis, which remained stable over time (p = 0.01). Most common postoperative complication was proximal junctional kyphosis (n = 4). However, no significant difference was found between groups regarding postoperative complications rate. CONCLUSION: CoCr and Ti rods both provide significant and stable frontal correction in AIS treated with posteromedial translation technique using hybrid constructs. However, CoCr might be considered to emphasize sagittal correction in hypokyphotic patients.

MRI of acute osteomyelitis in long bones of children: Pathophysiology study.

INTRODUCTION: The classic pathophysiology of acute osteomyelitis in children described by Trueta has a metaphyseal infection as the starting point. This hypothesis was recently brought into question by Labbé's study, which suggested a periosteal origin. Thus, we wanted to study this disease's pathophysiology through early MRI examinations and to look for prognostic factors based on abnormal findings. MATERIAL AND METHODS: This was a prospective, multicentre study that included cases of long bone osteomyelitis in children who underwent an MRI examination within 7days of the start of symptoms and within 24hours of the initiation of antibiotic therapy. We also collected clinical, laboratory and treatment-related data. RESULTS: Twenty patients were included, including one with a bifocal condition. The lower limb was involved in most cases (19/21). Staphylococcus aureus was found most frequently. Metaphyseal involvement was present in all cases. No isolated periosteal involvement was found in any of the cases. No prognostic factors were identified based on the various abnormal findings on MRI. CONCLUSION: Our study supports the metaphyseal origin of acute osteomyelitis in children. LEVEL OF EVIDENCE: II.

Unusual case of paediatric septic arthritis of the lumbar facet joints due to Kingella kingae.

A 32-month-old boy presented with febrile limping that had developed over 6days, associated with right lumbosacral inflammatory swelling. Magnetic resonance imaging (MRI) showed joint effusion of the right L5-S1 zygapophyseal joint, complicated by destructive osteomyelitis of the L5 articular process and paraspinal abscess. Surgery was decided to evacuate the fluid accumulation and rule out differential diagnoses. The diagnosis of septic arthritis of the facet joint was confirmed intraoperatively; real-time quantitative PCR analysis identified Kingella kingae. This is the first substantiated paediatric case of zygapophyseal joint septic arthritis due to K. kingae. K. kingae is the most common pathogen responsible for invasive osteoarticular infection in children under 4years of age. Since empiric antibiotics are effective in early stages, physicians should consider the possibility of spinal infections due to K. kingae when a limping child under 4years of age presents with a fever.

Intramuscular psoas lengthening during single-event multi-level surgery fails to improve hip dynamics in children with spastic diplegia. Clinical and kinematic outcomes in the short- and medium-terms.

BACKGROUND: In children with spastic diplegia, hip extension in terminal stance is limited by retraction of the psoas muscle, which decreases stride propulsion and step length on the contralateral side. Whether intramuscular psoas lengthening (IMPL) is effective remains controversial. The objective of this study was to assess the impact of IMPL as a component of single-event multi-level surgery (SEMLS) on spatial and temporal gait parameters, clinical hip flexion deformity, and hip flexion kinematics. HYPOTHESIS: IMPL as part of SEMLS does not significantly improve hip flexion kinematics. MATERIALS AND METHODS: A retrospective review was conducted of the medical charts of consecutive ambulatory children with cerebral palsy who had clinical hip flexion deformity (>10°) with more than 10° of excess hip flexion in terminal stance and who underwent SEMLS. The groups with and without IMPL were compared. Preoperative values of the clinical hip flexion contracture, hip flexion kinematics in terminal stance, and spatial and temporal gait parameters were compared to the values recorded after a mean postoperative follow-up of 2.4±2.0 years (range, 1.0-8.7 years). Follow-up was longer than 3 years in 6 patients. RESULTS: Of 47 lower limbs (in 34 patients) included in the analysis, 15 were managed with IMPL. There were no significant between-group differences at baseline. Surgery was followed in all limbs by significant decreases in kinematic hip flexion and in the Gillette Gait Index. In the IMPL group, significant improvements occurred in clinical hip flexion deformity, walking speed, and step length. The improvement in kinematic hip extension was not significantly different between the two groups. Crouch gait recurred in 3 (8%) patients. DISCUSSION: The improvement in kinematic hip extension in terminal stance was not significantly influenced by IMPL but was, instead, chiefly dependent on improved knee extension and on the position of the ground reaction vector after SEMLS. IMPL remains indicated only when the clinical hip flexion deformity exceeds 20°. LEVEL OF EVIDENCE: IV, retrospective study.

Flexibility analysis in adolescent idiopathic scoliosis on side-bending images using the EOS imaging system.

INTRODUCTION: Analysis of preoperative flexibility in adolescent idiopathic scoliosis (AIS) is essential to classify the curves, determine their structurality, and select the fusion levels during preoperative planning. Side-bending x-rays are the gold standard for the analysis of preoperative flexibility. The objective of this study was to examine the feasibility and performance of side-bending images taken in the standing position using the EOS imaging system. MATERIAL AND METHODS: All patients who underwent preoperative assessment between April 2012 and January 2013 for AIS were prospectively included in the study. The work-up included standing AP and lateral EOS x-rays of the spine, standard side-bending x-rays in the supine position, and standing bending x-rays in the EOS booth. The irradiation dose was measured for each of the tests. Two-dimensional reducibility of the Cobb angle was measured on both types of bending x-rays. RESULTS: The results were based on the 50 patients in the study. No significant difference was demonstrated for reducibility of the Cobb angle between the standing side-bending images with the EOS imaging system and those in the supine position for all types of Lenke deformation. The irradiation dose was five times lower during the EOS bending imaging. CONCLUSION: The standing side-bending images in the EOS device contributed the same results as the supine images, with five times less irradiation. They should therefore be used in clinical routine. LEVEL OF EVIDENCE: 2.

Fusionless surgery in early-onset scoliosis.

BACKGROUND: Surgical treatment of early-onset scoliosis has greatly developed in recent years. Early-onset scoliosis covers a variety of etiologies (idiopathic, neurologic, dystrophic, malformative, etc.) with onset before the age of 5 years. Progression and severity threaten respiratory development and may result in respiratory failure in adulthood. Many surgical techniques have been developed in recent years, aiming to protect spinal and thoracic development. MATERIAL AND METHODS: Present techniques are based on one of two main principles. The first consists in posterior distraction of the spine in its concavity (single growing rod, or vertical expandable prosthetic titanium rib [VEPTR]), or on either side (dual rod); this requires iterative surgery, for lengthening, unless motorized using energy provided by a magnetic system. The second option is to use spinal growth force to lengthen the assembly; these techniques (Luque Trolley, Shilla), using a sliding assembly, are known as growth guidance. RESULTS: These techniques are effective in controlling early scoliotic deformity, and to some extent restore spinal growth. However, they show a high rate of complications: infection, rod breakage, spinal fixation pull out and, above all, progressive spinal stiffness, reducing long-term efficacy. Respiratory gain is harder to assess, as thoracic expansion does not systematically improve respiratory function, particularly due to impaired compliance of the thoracic cage.

Severe slipped capital femoral epiphysis: A French multicenter study of 186 cases performed by the SoFOP.

INTRODUCTION: The treatment of severe slipped capital femoral epiphysis (SCFE) remains controversial. Despite numerous treatments being available, the outcome of published studies has been variable. Recent studies emphasize that poor reduction of the severe SCFE is responsible for the appearance of joint cartilage lesions and progression towards early osteoarthritis. But surgical reduction of severe SCFE also results in a significant rate of necrosis. OBJECTIVE: Evaluate the results of various treatment strategies for severe SCFE and identify the optimal course of action. MATERIAL AND METHODS: This was a French multicenter retrospective study of severe SCFE cases (>45° displacement) evaluated a minimum of 12 months after treatment. The stability of the slipped epiphysis, type of the treatment, delay before treatment, early and short-term complications, Harris and WOMAC functional scores and radiological signs of femoroacetabular impingement (FAI) at the last review were evaluated. A total of 186 cases of severe SCFE in 182 patients were included. One hundred and seven (58.7%) of these were male. The average age was 13 years. The average follow-up was 23 months. The average displacement was 60°. The SCFE was considered stable in 94 cases (50.5%) and unstable in 92 cases (49.5%). The main surgical treatments used by the various centers were in situ fixation (ISF), lateral Dunn, anterior Dunn and reduction using traction or under anesthesia (for unstable forms). RESULTS: In the stable SCFE cases, there were 6 cases of necrosis (6.4%), all of which occurred after reduction by osteotomy; there were 32 cases of radiological FAI (34%), 30 of which occurred after ISF. The necrosis rate in the unstable SCFE cases was 21.7%: one (11%) after ISF, seven (19%) after anterior Dunn, eight (21%) after preoperative reduction and three (43%) after lateral Dunn. CONCLUSIONS: The results of this study confirm the diverse nature of SCFE treatments available and the variability of their results. When selecting a treatment for severe SCFE, the goal is to stop the slip and also to prevent osteoarthritis by correcting the hip deformities. The "anterior" Dunn procedure was able to achieve these two goals, while having a lower complication rate than the other reduction techniques.

Feasibility of a reduction protocol in the emergency department for diaphyseal forearm fractures in children.

INTRODUCTION: Diaphyseal forearm fractures are very common pediatric traumas. At present, distal radius metaphyseal fractures are often successfully treated with closed reduction by emergency physicians. However, the management of diaphyseal fractures remains controversial. The purpose of this study was to analyze the results of diaphyseal forearm fractures in the emergency department (ED) in children. MATERIALS AND METHODS: In a prospective 2-year-study, all closed diaphyseal forearm fractures in patients under 15, with an angle of >15° and treated by closed reduction in the ED were included. Fractures with overlapping fragments were excluded. Reduction was performed by an emergency physician, with a standardized analgesic protocol (painkillers and nitrous oxide). Clinical tolerance was checked within the first 24hours, and the radiographic stability of reduction was assessed at days 8 and 15. Initial and final follow-up radiographs were analyzed. Elbow and wrist range of motion was assessed at the final follow-up. RESULTS: Sixty patients (41 boys and 19 girls) were included. Mean age was 5.2 years old (±3). At initial evaluation, the maximum angle was 30° (±11.3). After reduction, the maximum angle was significantly reduced (30° vs. 5°, P<0.001). Mean immobilization in a cast was 11.7 weeks (±2). There were no cast related complications in any of these children. There was no surgery for secondary displacement. Full range of motion was obtained in all patients at the final follow-up. DISCUSSION: The outcome of conservative treatment of closed diaphyseal forearm fractures, without overlapping fragments was excellent. However, reduction is usually performed in the operating room by orthopedic surgeons under general anesthesia and requires hospitalization, which is very expensive. The results of this study show that high quality care may be obtained in the ED by a trained and experienced team. These results are similar to those for distal metaphyseal fractures, which could extend the indications for reduction in the ED. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Dynamic balance assessment during gait in spinal pathologies - a literature review.

UNLABELLED: The role of the spine as a gait stabilizer is essential. Dynamic assessment, while walking, might provide complementary data to improve spinal deformity management. The aim of this paper was to review spine dynamic behavior and the various methods that have been used to assess gait dynamic balance in order to explore the consequences of spinal deformities while walking. A review was performed by obtaining publications from five electronic databases. All papers reporting pathological or non-pathological spine dynamic behavior during gait and dynamic balance assessment methods were included. Sixty articles were selected. Results varied widely according to pathologies, study conditions, and balance assessment techniques. Three methods assessing dynamic stability during gait were identified: local-orbital dynamic stability, tri-axial accelerometry, and dynamic stability margin. Data from conventional gait analysis techniques were established essentially for scoliosis and low back pain, but they do not assess specific consequences on gait dynamic balance. Three techniques investigate gait dynamic balance and have been validated in normal subjects. Further investigations need to be performed for validation in spinal pathologies as well as the value for clinical practice. LEVEL OF EVIDENCE: Level IV.

Sequelae of pediatric osteoarticular infection.

The epidemiology and diagnosis of osteoarticular infections (OAI) have changed considerably in recent years, partly due to the development of molecular biology. Kingella kingae is now recognized as the most frequent pathogen in children under 4 years of age, while methicillin-resistant Staphylococcus aureus (SA) has been increasingly reported. Although the clinical course of OAI is mostly benign, with shorter antibiotic regimens and simplified treatments, serious functional impairments and life-threatening complications can still occur, especially in case of delayed diagnosis or infection caused by Panton-Valentine leukocidin-producing strains of SA. Newborns and patients with sickle cell disease have greater risk of orthopaedic sequelae, which need to be detected and managed early. The main sequelae of osteomyelitis are angular limb deformity, due to partial growth arrest, and lower limb discrepancy. Therapeutic options are guided by the patient's age and predictions at maturity. The main complications of septic arthritis are joint stiffness and osteonecrosis. The procedures to consider are arthrodesis, joint reconstruction in immature children, and arthroplasty at the end of growth.

[Pseudotumoral soft tissue masses in children and adolescents]. / Masses des tissus mous d'allure tumorale de l'enfant et de l'adolescent.

INTRODUCTION: Pseudotumoral soft tissue masses in children and adolescents are a frequent reason for consultation and a diagnostic dilemma. Soft tissue malignancies are relatively uncommon, unlike the large number of benign lesions that may be seen in the superficial tissue and that can be diagnosed with clinical characteristics. MATERIALS AND METHODS: This retrospective study concerns 161 children and adolescents less than 20 years old, referred for a soft tissue mass between 2007 and 2011. It describes their epidemiology, clinical characteristics, and course of care to validate a diagnostic strategy for such masses. RESULTS: Final diagnoses were malignant tumors (44%), benign tumors (32%), and pseudotumoral lesions (24%). Clinical features were similar between these three groups except for age and tumor location, with more benign thoracic masses in younger children. Clinical and radiological association led to an accurate diagnosis for 50% of benign masses and with cytological analysis contribution in 79% of benign tumors and 86% of pseudotumoral lesions. Malignant tumors were suspected in only 39% of cases with radiological exams and in 89% after fine-needle aspiration, an essential additional diagnostic tool. Final diagnoses were formally established through simple standard clinical and radiological evaluation in 19 patients (11.8%; benign tumors, seven patients; malformations, eight patients; post-traumatic lesions, two patients; infection and inflammation, one patient each); ultrasound exam in five patients (3.1%; hemangioendotheliomas, two patients, fascial dehiscence, hemangioma, and vascular malformation, one patient each); MRI in four patients (2.5%; three vascular malformations and one lipoma); CT in two cases (1.2%; vascular malformation and myositis ossificans), and radiological examinations associated with cell aspiration in 15 cases (9.3%; ten benign tumors and five malignant tumors). CONCLUSIONS: A multidisciplinary approach should be requested from oncological, radiological, and pathologic experts to optimize soft tissue mass management as soon as initial investigations start. The authors advise a diagnostic strategy for children with pseudotumoral soft tissue masses.

Adolescent idiopathic scoliosis correction achieved by posteromedial translation using polyester bands: A comparative study of subtransverse process versus sublaminar fixation.

PURPOSE: Sublaminar polyester bands have been used in hybrid construct to achieve correction of adolescent idiopathic scoliosis since 2003. Despite the reported safety of the bands, some surgeons remain reluctant at the idea of approaching the canal because of the potential neurological complications reported with the Luque wiring. Sub transverse bands might be an alternative. The present study is the first to compare sublaminar polyester band fixation to fixation of polyester bands around the transverse processes in hybrid constructs used to treat AIS. METHODS: Two cohorts of consecutive patients treated for thoracic AIS were retrospectively reviewed, with a minimum 2-year follow-up. Posteromedial translation was used for main curve correction in all cases. Sublaminar polyester bands were used in group 1 (20 patients). In group 2 (20 patients), the same implant was used, but the bands were passed around the transverse process instead of the lamina. Radiographic analysis included frontal Cobb angle measurements for each curve, thoracic kyphosis and rotation of the apical vertebra (RVA). RESULTS: Mean operative time was similar in groups 1 and 2 (235±35 and 240±30minutes, respectively). Mean frontal correction achieved for the main curve was similar in both groups, 62.5±17.4% in group 1 and 54.1±19.4% in group 2. Sagittal correction was similar, with a final mean thoracic kyphosis of 30.9°±9.7° and 27.8°± 6.8° in group 1 and 2, respectively. Correction of RVA was similar in both groups postoperatively, 65.8% (±29.1) and 54.4% (±42.7) in group 1 and 2 respectively. No transverse process or lamina fracture was observed during insertion of the bands or curve correction in any of the groups. CONCLUSION: This study confirms that anchorage of Universal clamps (UCs) around transverse processes is a safe and efficacious technique in both the frontal and sagittal planes, providing a useful alternative for the correction of moderate AIS. UCs attached to transverse processes can achieve correction of moderate AIS similar to that obtained with sublaminar UCs while further reducing risks of vertebral canal complications. LEVEL OF EVIDENCE: Level IV.