[Release of amniotic constricted grooves by hemi-circumferential excision and skin closure without Z-plasty]. / Libérations des sillons de constriction amniotique par excision hémi-circonférentielle et fermeture cutanée sans plastie en Z.

INTRODUCTION: Constriction grooves are typical abnormalities of constriction band syndrome (CBS). Treatment by complete excision and Z-plastic closure is the gold standard for release of these grooves. However, the results of these Z-plasties are often judged to be aesthetically insufficient. The hypothesis was that direct excisional surgery without Z-plasty gave better aesthetic results. The objectives of this study were (1) to evaluate the clinicaal results of the release of amniotic furrows by simple hemi-circumferential excision without resorting to Z-plasties, (2) to study the occurrence of complications, (3) to study the factors leading to complications. MATERIALS AND METHODS: All patients who had release of amniotic grooves by linear hemi-circumferential excision and closure without Z-plasties were included between 2011 and 2017. Release of complete or circumferential grooves was carried out in 2 stages. Clinical evaluation was based on parental satisfaction with the aesthetic appearance and occurrence of any complications or recurrence. RESULTS: Fourteen grooves including 8 circumferential and 6 semi-circumferential were released, in 7 patients. Average age at surgery was 9 months (3-18 months). Some patients had 1, 2 or 3 surgeries. The groove was localized in 7 cases in the leg, in 4 in the fingers and in 1 in the thigh, toes and forearm. At the last average follow-up of 25 months (12-41 months), all parents were very satisfied with the aesthetic appearance. No complications, including scarring, vascular or lymphatic disease, were noted. No recurrence was noted. CONCLUSION: Release of amniotic grooves by simple linear hemi-circumferential excision without Z-plasties is a simple, safe and effective technique. The aesthetic results are very satisfactory. LEVEL OF EVIDENCE: IV - retrospective study.

Idiopathic clubfoot treatment and heterogeneity of current therapeutic strategies: The Ponseti method versus the French functional method (a systematic review).

BACKGROUND: Since Hippocrates, the treatment of idiopathic clubfoot has undergone many changes, with surgical techniques and conservative approaches evolving over the centuries. Today, a wide variety of practices exist in France and throughout the world; consequently, the treatment of idiopathic clubfoot remains controversial, but the Ponseti method and the functional method seem to stand out. Nevertheless, has one of them demonstrated superiority? METHODS: The purpose of this review is to compare these two methods. Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 recommendations, this research was conducted on Pubmed, Web of Science, and 1Findr. Only articles concerning patients with moderate or severe idiopathic clubfoot (10-17 on the Dimeglio scale) treated early using the Ponseti method or the functional method were eligible. RESULTS: After reviewing 49 studies, seven published between 2008 and 2018 were selected: five prospective cohort studies, one retrospective cohort study, and one meta-analysis. Each method, according to morphological and kinetic criteria, seems to have advantages that the other does not have. CONCLUSIONS: Although the Ponseti method is becoming the gold standard and appears more appropriate in poor countries, it is impossible to affirm its superiority over the functional method. Therefore, the combination of their advantages deserves attention: a hybrid method could be an appealing prospect for the future.

Assessing the management of pediatric bone and joint infections according to French guidelines.

BACKGROUND: Short treatments for acute bone and joint infections (BJI) are recommended. We implemented a protocol in 2009 to improve diagnosis and bacteriological documentation, and to shorten antibiotic therapies as per French guidelines (French Pediatric Infectious Disease Group, GPIP). METHODS: To assess the impact of the new clinical protocol for BJI, we conducted a retrospective study from January 1st, 2006 to August 31st, 2012. Two successive cohorts were compared, before and after protocol implementation. All children suspected of community-acquired BJI were included. Confirmed osteomyelitis and septic arthritis required a positive bacterial isolate; otherwise, cases were considered probable. We compared clinical, biological, and radiological data; duration of antibiotic therapy and hospital length of stay; and complications and sequelae. RESULTS: A total of 377 children with suspected BJI were included. The bacteriological identification improved from 32% to 44% when patients were completely evaluated. Isolated bacteria were Staphylococcus aureus (53%), Kingella kingae (17%), Streptococcus pyogenes (15%), and Streptococcus pneumoniae (8%). Before protocol implementation, 70% of patients had a central venous line versus 9% after implementation. Mean duration of IV antibiotics (11 days versus 6 days), mean duration of total antibiotic therapy (45 days versus 32 days) and mean hospital length of stay (13 days versus 7 days) had significantly improved. CONCLUSION: Improvement in bacteriological diagnosis and shorter antibiotic regimens lead to shorter hospital length of stays with no additional morbidity. Simplifying the protocol and better diffusion among health professionals should contribute to shortening BJI treatment duration.

Bone reconstruction after malignant tumour resection using a motorized lengthening intramedullary nail in adolescents: preliminary results.

PURPOSE: Bone reconstruction after malignant tumour of the lower limbs is a challenge. Our aim was to investigate the results of bone lengthening and transport using the Fitbone motorized lengthening nail. METHODS: Eight patients were included. Two patients had had a tumour involving soft tissue only without bone resection. In six patients, the initial bone defect was 15.5 cm (8 to 24). The first step of reconstruction had consisted of temporary fixation and a cement spacer. The second step had consisted of bone grafting in five patients. One patient was managed with bone transport. Eventually, five patients had a limb-length discrepancy (LLD) managed with bone lengthening only. Two patients had a LLD and a nonunion managed with bone transport and lengthening. Mean age at bone lengthening was 15.2 years (11 to 19). Mean follow-up was 30.5 months (10 to 48). RESULTS: In all, 11 nails were implanted in eight patients (eight femurs, three tibias). Mean length gain per procedure was 54.5 mm (30 to 80). Mean healing index was 48.4 days per cm (22.6 to 85.7). The complication rate was 18%. In two cases we observed a loose locking screw, which was revised. In all cases the lengthening involved the short bone (femur or tibia). Mean Musculoskeletal Tumor Society (MSTS) score improved from 52.7 (16.6 to 73.3) to 79.9 (63.3 to 96.6). CONCLUSIONS: Bone reconstruction using a motorized intramedullary nail stands as a safe and reliable alternative after malignant tumour. It allows biological reconstruction with satisfactory clinical and radiological outcome and low complication rate. LEVEL OF EVIDENCE: III.

Osteochondritis dissecans of the knee.

Osteochondritis dissecans (OCD) of the knee is an idiopathic, focal, subchondral-bone abnormality that can cause instability or detachment of a bone fragment and overlying articular cartilage, with subsequent progression to osteoarthritis. The diagnosis is usually made during adolescence. Mechanical factors play a major role in the pathophysiology of OCD. When the radiographic diagnosis is made early in a patient with open physes, healing can often be obtained simply by restricting sports activities. The degree of lesion instability can be assessed by magnetic resonance imaging. When the lesion remains unstable and the pain persists despite a period of rest, surgery is indicated. Arthroscopic exploration is always the first step. Drilling of the lesion produces excellent outcomes if the lesion is stable. Unstable lesions require fixation and, in some cases, bone grafting. Defects must be filled, depending on their surface area. Although many surgical techniques are available, the therapeutic indications are now standardized.

Salvage of congenital pseudarthrosis of the tibia by the induced membrane technique followed by a motorised lengthening nail.

An 18-year-old male with neurofibromatosis type I was treated for congenital pseudarthrosis of the tibia using the Masquelet induced-membrane technique with internal fixation by retrograde implantation of a transplantar intramedullary nail. Bone healing was obtained at the expense of malunion with external rotation and 5.5cm of lower limb shortening. A motorised intramedullary-lengthening nail (Fitbone®, Wittenstein, Igersheim, Germany) was implanted. This treatment was successful in correcting the rotational malalignment and limb length discrepancy. The motorised nail Fitbone® may be a valid option for treating complex cases of limb length discrepancy, including those combined with limb deformities.

Relevance of MRI for management of non-displaced lateral humeral condyle fractures in children.

INTRODUCTION: The treatment for non-displaced (<2 mm displacement) fractures of the lateral humeral condyle in children is controversial. Most studies recommend non-surgical treatment. However, plain radiographs are not sufficient to evaluate extension of the fracture line through the articular cartilage. This explains the high frequency of secondary displacements and non-unions, despite well-conducted conservative treatment. We hypothesized that MRI could be used to analyse whether the fracture is complete or incomplete. This could help to determine whether surgical or conservative treatment is indicated. MATERIAL AND METHODS: This prospective study enrolled children being treated for a non-displaced (< 2 mm gap) fracture of the lateral humeral condyle. All patients were treated with a long-arm cast in the emergency room. An MRI was done later on without sedation. A specific protocol was used to reduce the duration of the examination. T2-weighted and proton density fat-saturated sequences were used. RESULTS: Twenty-seven patients were enrolled: 16 boys and 11 girls with a mean age of 5 years (2-10). The MRI was performed an average of 7 days (1-23) after the fracture. The MRI could not be interpreted in two cases because the child had moved during the examination. In the other 25 patients, the fracture was incomplete in 17 patients and complete in 8 patients. Two children had secondary displacement diagnosed 7 and 11 days after the fracture event. These two patients underwent open reduction and internal fixation. There was no correlation between patient age and the fracture being complete or incomplete. There were no cases of non-union. CONCLUSION: MRI appears to be a reliable method for determining whether the fracture line is complete or incomplete. It can be performed without sedation, even in children as young as 2 years of age. Use of an injury-specific MRI protocol reduces the length of the examination, thereby improving its performance. We recommend that it be used to analyse non-displaced fractures of the lateral humeral condyle in children. LEVEL OF EVIDENCE: 3 Prospective study.

Five-year outcomes of the First Distal Uninstrumented Vertebra after posterior fusion for Adolescent Idiopathic Scoliosis Lenke 1 or 2.

BACKGROUND: Tilt of the First Distal Uninstrumented Vertebra (FDUV) reflects changes in the main curve and compensatory lumbar curve after posterior fusion to treat thoracic Adolescent Idiopathic Scoliosis (AIS). HYPOTHESIS: FDUV tilt 5 years or more post-fusion depends chiefly on reduction of the main curve and on other factors such as selection of the last instrumented vertebra. MATERIAL AND METHOD: A multicenter retrospective cohort of 182 patients with Lenke 1 or 2 AIS treated with posterior instrumentation and followed up for a mean of 8 years and a minimum of 5 years was studied. The patients were divided into two groups based on whether tilt of the upper endplate of the FDUV was ≤5° or >5°at last follow-up. Variables associated with tilt were identified by multiple logistic regression. RESULTS: Six variables were significantly associated with FDUVtilt: percentage of correction at last follow-up, correction loss, lumbar modifier B, number of instrumented vertebrae, inclusion within the instrumentation of the distal neutral vertebra, and inclusion within the instrumentation of the lowest vertebra intersected by the central sacral vertical line. DISCUSSION AND CONCLUSION: The main variables associated with FDUVtilt ≤5° were a final correction percentage ≥60% and absence of correction loss between the postoperative period and last follow-up. Given the stable reduction provided by contemporary instrumentations, we recommend selective thoracic fusion of Lenke 1 or 2 AIS with lumbar modifiers A, B, and C. The lowest instrumented vertebra should be either the neutral vertebra or the vertebra intersected by the central sacral vertical line if it is distal to the neutral vertebra. LEVEL OF EVIDENCE IV: Retrospective multicenter study.

Pediatric orthopedic surgery in humanitarian aid.

Pediatric orthopedic surgery in humanitarian aid is conducted mainly in cooperation with emerging countries. Each mission is different, and depends on numerous parameters such as the country, the frequency of such missions, the pathologies encountered, the local structure and team, and the non-governmental organization (NGO) involved. Pathologies vary in etiology (tuberculosis, poliomyelitis) and severity. Each mission requires the presence of an experienced surgeon. Working conditions are often rudimentary. Surgical indications should be restricted to procedures that are going to be effective, with minimal postoperative complications, without any surgical "acrobatics". Teaching should be in association with the local university, and adapted to local needs. Mission objectives need to be realistic. Surgical indications should be adapted to local conditions, and the surgeon needs to be able to say "no" to procedures involving undue risk. The surgeon on mission should cooperate with local teams and be able to adapt to unusual situations. Assessment of results is essential to improving efficacy and evaluating the success of the mission.

Arthroscopic treatment of intercondylar eminence fractures with intraepiphyseal screws in children and adolescents.

INTRODUCTION: Tibial intercondylar eminence fracture rarely occurs in childhood. Its treatment requires anatomic reduction to provide knee stability and a rigid fixation to minimize postoperative immobilization time. HYPOTHESIS: Arthroscopy combined with fluoroscopy with intra-epiphyseal ASNIS screw fixation can meet the requirements of this treatment. MATERIAL AND METHODS: The series comprised 24 patients (mean age: 11 years) with Meyers and McKeever type II tibial intercondylar eminence fractures (n=15) or type III (n=9), operated on between 2011 and 2013. Fixation with 4-mm ASNIS screws was placed arthroscopically. The demographic data, associated lesions, radiological union, stability, functional result, and the Lysholm score were evaluated. RESULTS: With a mean follow-up of 2 years, the mean Lysholm score was 99.3 for type II and 98.6 for type III fractures. At the 6th postoperative week, range of motion in the operated knees was identical to the healthy knees. At the 12th postoperative week, there was no sign of anterior laxity. Twelve cases included meniscal entrapment, but no significant difference was observed in the functional results. DISCUSSION, CONCLUSION: ASNIS screw fixation under arthroscopy can be successfully applied in the treatment of types II and III tibial intercondylar eminence fractures in children. This technique provides excellent stability, allows early weigh-tbearing, and preserves function of the knee and its growth. LEVEL OF EVIDENCE: IV, retrospective study.

Bone lengthening using the Fitbone(®) motorized intramedullary nail: The first experience in France.

INTRODUCTION: Intramedullary limb lengthening systems include mechanical systems (the Albizzia nail and the ISKD nail) as well as motorized systems with the Fitbone(®) (Wittenstein, Igersheim, Germany) and the Precice(®) (Ellipse Technologies, Irvine, CA, USA) nails. We hypothesized that limb lengthening using the Fitbone(®) nail was reliable, reproducible, and comfortable for the patient. PATIENTS AND METHODS: Between 2010 and 2013, a prospective single-center, single-operator (FA) study was conducted on patients who had undergone limb lengthening using the Fitbone(®) nail. The inclusion criteria were length discrepancy of the limbs equal to or greater than 25 mm or a short stature. The exclusion criteria were indications for cosmetic reasons and/or growth plates that were still open. The lengthening parameters were assessed postoperatively and at the last follow-up. Lengthening was considered achieved when the lengthening objective did not differ by more than 5 mm. All complications were noted. A statistical analysis was performed. RESULTS: Twenty-six Fitbone(®) nails were implanted in 23 patients, in the femur in 15 cases and the tibia in 11 cases. The patients' mean age was 22.5 years (range: 15-53 years) and the mean follow-up was 3.4 years (range: 2-5.3 years). The limb lengthening targeted was obtained in 23 cases (88%) and the mean lengthening was 45.3±18 mm (range: 20-80 mm). The mean time to healing was 277±167 days (range: 86-638 days). The mean healing index was 73±57 days/cm for the femurs and 83.5±65 days/cm for the tibias. The mean complication rate was 15.4%. DISCUSSION: This study emphasizes the good short-term results of this motorized intramedullary lengthening system. An evaluation over the longer term and with a higher number of patients remains necessary. LEVEL OF EVIDENCE: IV: uncontrolled, prospective, continuous study.

Whole-exome sequencing in osteosarcoma reveals important heterogeneity of genetic alterations.

BACKGROUND: Whole-genome sequencing studies have recently shown that osteosarcomas (OSs) display high rates of structural variation, i.e. they contain many somatic mutations and copy number alterations. TP53 and RB1 show recurrent somatic alterations in concordant studies, suggesting that they could be key players in bone oncogenesis. PATIENTS AND METHODS: we carried out whole-genome sequencing of DNA from seven high-grade OS samples matched with normal tissue from the same patients. RESULTS: We confirmed the presence of genetic alterations of the TP53 (including novel unreported mutations) and RB1 genes. Most interestingly, we identified a total of 84 point mutations and 4 deletions related to 82 different genes in OS samples, of which only 15 have been previously reported. Interestingly, the number of mutated genes (ranging from 4 to 8) was lower in TP53mut cases compared with TP53wt cases (ranging from 14 to 45). This was also true for the mutated RB1 case. We also observed that a dedifferentiated OS harboring MDM2 amplification did not carry any other mutations. CONCLUSION: This study suggests that bone oncogenesis driven by TP53 or RB1 mutations occurs on a background of relative genetic stability and that the dedifferentiated OS subtype represents a clinico-pathological entity with distinct oncogenic mechanisms and thus requires different therapeutic management.

Complex regional pain syndrome type I in children. Clinical description and quality of life.

INTRODUCTION: Complex regional pain syndrome type 1 (CRPS I) in children differs from its adult counterpart and relevant literature is scarce. Our aim was to investigate potential risk factors and to assess midterm outcome and quality of life. MATERIAL AND METHODS: Medical records of patients diagnosed with CRPS I between 2004 and 2012 were analyzed. Patients and parents were called for a phone interview including the PEDS Quality of Life 4-0 questionnaire. Results were compared to a control group matched for age, gender and socio-economic status. RESULTS: Seventy-three patients were included (64 girls, 9 boys). Mean age at diagnosis was 11.5 years and mean time to diagnosis was 14.2 months. The lower limb was affected in 89% of cases. Allodynia, coldness and cyanosis were noted in 95%, 81% and of 74% of cases, respectively. Forty-nine percent of patients reported a physical injury. Multivariate analysis showed a strong association with being anxious (OR = 44.9, 95% CI [7.4-273]), presence of an atopic background (OR = 25.0, 95% CI: [4.6-135]), being good to excellent school performers (OR = 8.4 95% CI [1.3-52.1]), and having trouble falling asleep (OR = 5.3, 95% CI [1.6-17.0]). At a mean 37 months' follow-up (12-102), PEDS QL 4-0 score was significantly lower in CRPS patients compared to controls. Fifty-seven percent of patients acknowledged healing and 55% had presented a relapse. CONCLUSION: Childhood onset CRPS I affects predominantly preadolescent girls at the ankle. The present study highlights the relatively poor outcome, especially its physical and emotional aspects and the large role of psychology. LEVEL OF EVIDENCE: IV.

Evolution of adolescent idiopathic scoliosis: results of a multicenter study at 20 years' follow-up.

INTRODUCTION: To date there is no consensus on therapeutic indications in adolescent idiopathic scoliosis (AIS) with curvature between 30° and 60° at the end of growth. OBJECTIVE: The objective of this study was to assess outcome in patients with moderate AIS. MATERIAL AND METHODS: A multicenter retrospective study was conducted. Inclusion criteria were: Cobb angle, 30-60° at end of growth; and follow-up > 20 years. The data collected were angular values in adolescence and at last follow-up, and quality of life scores at follow-up. RESULTS: A total of 258 patients were enrolled: 100 operated on in adolescence, 116 never operated on, and 42 operated on in adulthood. Mean follow-up was 27.8 years. Cobb angle progression significantly differed between the 3 groups: 3.2° versus 8.8° versus 23.6°, respectively; P < 0.001. In lumbar scoliosis, the risk of progression to ≥ 20° was significantly higher for initial Cobb angle > 35° (OR=4.278, P=0.002). There were no significant differences in quality of life scores. DISCUSSION: Patients operated on in adolescence showed little radiological progression, demonstrating the efficacy of surgical treatment for curvature greater than 50°. Curvature greater than 40° was progressive and may require surgery in adulthood. Lumbar scoliosis showed greater potential progression than thoracic scoliosis in adulthood, requiring fusion as of 35° angulation. LEVEL OF EVIDENCE: IV, retrospective study.

Isolated meniscal injuries in paediatric patients: outcomes after arthroscopic repair.

BACKGROUND: The management of isolated meniscal tears in paediatric patients is poorly standardised, and few published data are available. Nevertheless, there is widespread agreement that meniscectomy, even when partial, produces poor outcomes including the premature development of osteoarthritis. HYPOTHESIS: Arthroscopic repair of isolated meniscal tears in paediatric patients yields good outcomes and should be attempted routinely. MATERIALS AND METHODS: We retrospectively assessed 19 arthroscopic repair procedures performed between 2006 and 2010 by a single surgeon in 17 patients with a mean age of 14 years. In every case, the knee was stable and the meniscus normal before the meniscal tear, which was the only injury. Mean follow-up was 22 months. In all 19 cases, the evaluation included a physical examination, pre-operative magnetic resonance imaging (MRI), and determination of the Tegner and Lysholm scores. Post-operative MRI was performed in 10 cases. RESULTS: The outcome was good in 12/17 (70%) patients with significant improvements in the mean Tegner score, from 3.9 to 7.1, and mean Lysholm score, from 55.9 to 85.4, between the pre-operative and post-operative assessments. The clinical outcomes were not significantly associated with time to arthroscopic repair, gender, lesion site, or lesion type. Neither was any correlation demonstrated between clinical outcomes and meniscal healing as assessed by MRI. DISCUSSION: The known poor outcomes after meniscectomy in paediatric patients, the results of our study, and previously published data support routine arthroscopic repair of isolated meniscal tears in this age group, regardless of the site and type of injury. In addition, in asymptomatic patients, clinical follow-up is sufficient and post-operative MRI unnecessary. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Proximal ulnar osteotomy in the treatment of neglected childhood Monteggia lesion.

INTRODUCTION: The aim of our study was to analyze medium and long-term results of proximal ulnar osteotomy with and without ligament injury in neglected Monteggia injury in children. MATERIAL AND METHODS: This retrospective, multicenter study included 28 patients. Clinical criteria concerned the range of motion, pain and MEPI score, and radiologic criteria comprised of Storen line, head-neck ratio, radial neck angle, and signs of osteoarthritic remodeling. RESULTS: Twenty-eight patients were reviewed, at a mean 6 years' follow-up (range, 2-34y). Sixteen had proximal ulnar osteotomy without ligament reconstruction, and 12 had associated ligamentoplasty. Both groups showed significant clinical and radiological improvement, with no significant difference. Patients operated within less than 1 year had better clinical and radiographic results. There was no correlation between age at surgery and quality of results. The 5 patients who underwent condyloradial pinning showed early recurrence of dislocation and osteoarthritic remodeling. The three cases of Bado type-3 lesion had early recurrence of dislocation. DISCUSSION: Proximal ulnar osteotomy gives good long-term results in Bado type-1 lesions, regardless of age, if performed before 1 year, in the absence of osteoarthritic remodeling. Associated ligamentoplasty does not seem to be useful. LEVEL OF EVIDENCE: IV (retrospective).

Prognosis value of early diffusion MRI in Legg Perthes Calvé disease.

PURPOSE: To evaluate diffusion MRI of the proximal femoral epiphysis and metaphysis as a prognosis factor in Legg Calvé Perthes (LCP) disease. METHODS: Thirty-one children (mean age 5.5 years, range 2.5-10.5) with unilateral LCP were included in a prospective, consecutive series. Radiographs were analysed and classified as per Herring criteriae. Mean follow-up was 19 months (range 6-30). Forty-nine MRI scans were performed at either the condensation or fragmentation stage. Apparent Diffusion Coefficient (ADC) of both the femoral epiphysis and metaphysis were measured bilaterally and ADC ratio were calculated, then compared to the Herring group. RESULTS: Sixteen hips were rated Herring A or B, 3 Herring B-C and 12 Herring C. ADC was increased in affected hips compared to unaffected sides, both at the femoral epiphysis (P<0.001) and metaphysis (P<0.0001). ADC ratio of the femoral metaphysis was positively correlated to Herring classification: if superior to 1.63, it was associated with a bad prognosis (Herring B-C or C) (P=0.0017, sensitivity=89%, specificity=58%). Interobserver reliability of ADC measurement was excellent. The 1.63 threshold could be determined as early as the condensation stage. CONCLUSIONS: Diffusion presents several advantages including being non radiating and non invasive. It does not need contrast medium administration and it can be performed without anaesthesia. The origin of the increased ADC remains unknown. Basically, it reflects molecular changes (true diffusion) but it is also influenced by the vascular supply (pseudo-diffusion). ADC ratio could provide an early prognosis before Herring classification is applicable. LEVEL OF EVIDENCE: Level III. Prospective uncontrolled study.

Percutaneous correction of congenital overlapping fifth toe in paediatric patients.

The various available surgical methods for correcting congenital overlapping fifth toe deformity consistently require a skin plasty step, which can result in complications (necrosis, tight scar, unbecoming appearance). Here, we describe a percutaneous technique involving extensor tenotomy combined with release of the dorso-medial capsule and ligaments. No skin plasty is required. Percutaneous osteotomy of the first phalanx can be performed if needed. From 2006 to 2010, we used this technique in 16 patients (27 toes) with a mean age of 12.6years (range, 6-17years). Mean follow-up at last evaluation was 2.1 years. Osteotomy of the first phalanx was performed for 13 toes. The outcome was very good for 21 toes and good for six toes. No relapses or complications were recorded. This simple and safe technique deserves consideration in children with congenital overlapping fifth toe.

Intraoperative neurophysiologic monitoring in spine surgery. Developments and state of the art in France in 2011.

Intraoperative spinal cord monitoring consists in a subcontinuous evaluation of spinal cord sensory-motor functions and allows the reduction the incidence of neurological complications resulting from spinal surgery. A combination of techniques is used: somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), neurogenic motor evoked potentials (NMEP), D waves, and pedicular screw testing. In absence of intraoperative neurophysiological testing, the intraoperative wake-up test is a true form of monitoring even if its latency long and its precision variable. A 2011 survey of 117 French spinal surgeons showed that only 36% had neurophysiological monitoring available (public healthcare facilities, 42%; private facilities, 27%). Monitoring can be performed by a neurophysiologist in the operating room, remotely using a network, or directly by the surgeon. Intraoperative alerts allow real-time diagnosis of impending neurological injury. Use of spinal electrodes, moved along the medullary canal, can determine the lesion level (NMEP, D waves). The response to a monitoring alert should take into account the phase of the surgical intervention and does not systematically lead to interruption of the intervention. Multimodal intraoperative monitoring, in presence of a neurophysiologist, in collaboration with the anesthesiologist, is the most reliable technique available. However, no monitoring technique can predict a delayed-onset paraplegia that appears after the end of surgery. In cases of preexisting neurological deficit, monitoring contributes little. Monitoring of the L1-L4 spinal roots also shows low reliability. Therefore, monitoring has no indication in discal and degenerative surgery of the spinal surgery. However, testing pedicular screws can be useful. All in all, thoracic and thoracolumbar vertebral deviations, with normal preoperative neurological examination are currently the essential indication for spinal cord monitoring. Its absence in this indication is a lost opportunity for the patient. If neurophysiological means are not available, intraoperative wake-up test is a minimal obligation.