False aneurysm of the popliteal artery revealing a solitary osteochondroma of the distal femur in an 11-year-old boy.

An 11-year-old boy presented with pain in the right knee, intermittent reverse ischemia of the right foot and paraesthesia of the right toes. An angio-CT showed a false aneurysm of the right superior popliteal artery, and a solitary osteochondroma of the posterior aspect of the distal femur. Excision of the aneurysm and the osteochondroma was performed in two-stages. The patient was clinically well at 1-year follow up.

Tailor-made management of thoracic scoliosis with cervical hyperextension in muscular dystrophy.

PURPOSE: We report the case of a 13-year-old boy managed for fixed cervical hyperextension due to congenital muscular dystrophy with partial merosin deficiency. He presented a right decompensated thoracic scoliosis (T6-L1 Cobb angle 72°) associated with cervical and lumbar lordosis. The spinal extension was accompanied by major flexion of the hip resulting in the trunk being bent forward. This posture caused daily severe back pain responsible for significant loss of quality of life. This led to the decision to perform surgery. METHODS: Initially, the surgery was limited to the thoraco-lumbo-sacral area. An anterior release was done, followed by posterior T1-pelvis vertebral fusion using a modified Luque-Galveston technique. The correction achieved was satisfactory in the coronal plane, but the correction of the thoracic kyphosis was insufficient to compensate for the cervical hyperextension. Cervical spine was fixed at 52° of lordosis, and associated with a left 50° rotation and a right 45° inclination of the head. We performed a posterior and lateral release of the cervical muscles followed by positioning of the halo, itself connected to a made-for-measure thoracic corset. A daily adjustment of the threaded rods was done daily for 3 months to correct the cervical position. Then, we performed a spinal fusion without instrumentation, by posterior articular abrasion and grafting from the occiput to T1. Following that, the halo-corset was kept in place for 4 months. RESULTS: At the end of 8 month treatment, the clinical result was satisfactory with a balanced spine both face on, and sideways, allowing for comfortable painless positioning. At 5 year follow-up, he showed stable spinal fusion without any loss of correction. CONCLUSION: There is no gold standard treatment for cervical hyperextension, but approaches have to be tailor-made to the patient's needs and the team's experience.

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.

Urethral duplication in girls: Three cases associating an accessory epispadiac urethra and a main hypospadiac urethra.

INTRODUCTION: Urethral duplication is extremely rare in girls, with less than 40 cases reported so far. Most of them present as a prepubic sinus. Literature is scare regarding aetiology, classification and management in other forms. This study presents three cases of sagittal urethral duplication in girls presenting a main hypospadiac urethra and an accessory epispadiac urethra. PATIENTS AND METHODS: Medical records were retrospectively reviewed of three girls with urethral duplication managed over a 30-year period at a single institution. Circumstances of diagnosis, management and outcomes were analysed. RESULTS: The oldest case presented as a neonatal retrovesical mass with an accessory clitoral stream, whereas the two more recent cases presented with antenatal hydrocolpos and bilateral ureterohydronephrosis. Cases 1 and 3 had an incomplete duplication, while Case 2 had a complete form. In Case 3, the duplication was associated with a urogenital sinus and an anteriorly placed anus. Management involved resection of the epispadiac accessory urethra to achieve continence, with dilatation and/or mobilisation of the hypospadiac one. All girls are now aged >5 years old and are continent, and one is old enough to have normal menstruation. Renal function is normal in all. The summary table presents the schematic anatomical description as shown on micturating cystourethrogram and endoscopy, as well as the management for each patient. DISCUSSION: Step-by-step management is necessary in urethral duplication. The neonatal emergency is to release the urinary tract compression by evacuating urinary retention or hydrocolpos. Later in infancy, decision has to be taken regarding the urethras. If the resection of the epispadiac accessory urethra seems acceptable to achieve continence, the attitude towards the hypospadiac channel is more controversial and should be individualised. Embryologic and aetiopathogenic pathways are still missing to uniformly characterise the malformation. CONCLUSION: Paediatric urologists should remember that there is a wide spectrum of urethral duplication in girls, and that various presentations exist beside the more classic prepubic sinus.

A new procedure for fractures of the medial epicondyle in children: Mitek(®) bone suture anchor.

We present a new bone suture anchor technique for fractures of the medial epicondyle. The hypothesis was that the results would be similar to those with the divergent K-wire fixation. This retrospective study included 40 patients who presented with displaced fractures of the medial epicondyle: one group was treated with a Mitek(®) non-resorbable bone suture anchor (group A: n=21), the other by K-wire fixation (group B: n=19). A medial approach was taken with an anchor placed above the olecranon fossa. The epicondyle was then repositioned by bone suture. After a mean follow-up of 18.6 months, union was obtained in all epicondyles. There was no difference in flexion-extension of the elbow. The rate of hypertrophy of the medial epicondyle was similar in both groups (57%). The bone suture anchor of the medial epicondyle is an effective technique that does not require hardware removal and is an alternative treatment option to divergent K-wire fixation.

Proximal humerus fractures in children and adolescents.

Proximal humerus fractures are rare in paediatric traumatology. Metaphyseal fractures account for about 70% of cases and epiphyseal separation for the remaining 30%. The development and anatomy of the proximal humerus explain the various fracture types, displacements, and potential complications; and also help in interpreting the radiographic findings, most notably in young children. Physicians should be alert to the possibility of an underlying lesion or pathological fracture requiring appropriate diagnostic investigations, and they should consider child abuse in very young paediatric patients. Although the management of proximal humerus fractures remains controversial, the extraordinary remodelling potential of the proximal humerus in skeletally immature patients often allows non-operative treatment without prior reduction. When the displacement exceeds the remodelling potential suggested by the extent of impaction, angulation, and patient age, retrograde elastic stable intramedullary nailing (ESIN) provides effective stabilisation. As a result, the thoraco-brachial abduction cast is less often used, although this method remains a valid option. Retrograde ESIN must be performed by a surgeon who is thoroughly conversant with the fundamental underlying principles. Direct percutaneous pinning is a fall-back option when the surgeon's experience with ESIN is insufficient. Finally, open reduction is very rarely required and should be reserved for severely displaced fractures after failure of closed reduction. When these indications are followed, long-term outcomes are usually excellent, with prompt resumption of previous activities and a low rate of residual abnormalities.

Early correction of paediatric malunited distal metaphyseal radius fractures using percutaneous callus osteoclasis ("Calloclasis").

INTRODUCTION: Closed reduction of secondary displacements of distal metaphyseal radius fractures is an easy procedure only when performed within the first ten to fifteen days post-trauma, prior to the occurrence of malunion. When a hard bony callus prevents proper reduction, an open osteotomy is generally advocated. HYPOTHESIS: We suggest the use of a less invasive technique which aims at correcting early malunion when closed reduction is made impossible: the percutaneous callus osteoclasis. MATERIALS AND METHODS: Callus osteoclasis consists in a series of multiple bone-drilling in a postage stamp pattern performed under image intensifier using a large diameter pin, at a distance from the growth plate. Once the bone has been weakened, reduction is obtained by using the pin as an intrafocal lever. The pin is then pushed through the opposite cortex to ensure postero-lateral stabilization. RESULTS: Twenty-one patients were managed using this technique and reported good results with no complications. DISCUSSION: This technique offers a low aggressive management of malunions and may be performed within two to six weeks after trauma. LEVEL OF EVIDENCE: Level IV. Multicenter retrospective study.

Fixator-assisted medial tibial plateau elevation to treat severe Blount's disease: outcomes at maturity.

INTRODUCTION: Severe forms of Blount's disease may be associated with medial tibial plateau (MTP) depression. Management should then take account of joint congruence, laxity, limb axis, torsional abnomality, leg length discrepancy (LLD) and eventual recurrence history. PATIENTS AND METHODS: Eight knees (six patients) were managed in a single step comprising MTP elevation osteotomy, lateral epiphysiodesis and proximal tibia osteotomy to correct varus and rotational deformity. Fixation was achieved using an Ilizarov external fixator. Mean age was 10.5 years. Mean hip-knee-ankle (HKA) angle was 151°; distal femoral varus, 94°; metaphyseal-diaphyseal angle (MDA), 27°; and angle of depression of the medial tibial plateau (ADMTP), 42°. Predicted residual proximal tibial growth was 2.6 cm. RESULTS: At a mean 48 months' follow-up, results were good in six cases, medium in one and poor (due to incomplete lateral epiphysiodesis) in one. Mean lateral tibial torsion was 9° and final LLD 11 mm. Weight-bearing was resumed at 2 months, and the fixator was removed at 5.5 months postoperatively. At end of follow-up, mean HKA angle was 179.6°, MDA 7.3° and ADMTP 5.4°. DISCUSSION: This technically demanding procedure gave satisfactory results in terms of axes and congruence; longer term assessment remains needed. LEVEL OF EVIDENCE: Level IV. Retrospective study.

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

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

[Influences of induced membranes on heterotopic bone formation within an osteo-inductive complex. Experimental study in rabbits]. / Influence des membranes induites sur l'ostéogenèse hétérotopique au sein d'un complexe ostéo-inducteur. Etude expérimentale chez le lapin.

UNLABELLED: Based on a new concept, a procedure combining induced membranes and cancellous autografts allows the reconstruction of wide diaphyseal defects. To date, this procedure is limited by the amount of cancellous bone available from the patient and by the related morbidity at the donor site. The aim of this study was to evaluate the biological effect of induced membranes on a cylindrical-shaped ceramic implants loaded with OP-1 in heterotopic site. MATERIALS AND METHODS: Sixty hydroxyapatite tricalcium phosphate (HA-TCP) implants, 20 of which being loaded with a bone growth factor (rhOP-1) were inserted either in a subcutaneous tunnel or within a previously induced membrane on the back of rabbits. There were two time-points at four and 16 weeks. Implants were investigated at three different levels (extremities and middle). RESULTS: None of the untreated implants showed any evidence of bone formation. Implants inserted in an induced membrane presented with less resorption. Bone ingrowth within the pores of the materials was significantly higher when the implants were inserted into the induced membrane whatever the time-point considered. CONCLUSION: The membrane seems to play the role it was assigned, i.e. to protect and revascularize the implant, thus favouring osteogenesis that occurs in 80% of the implants after four months.

Roles of soil chemistry and water availability in site-related delta(13)C variations in French beech forests.

The carbon isotopic composition (delta(13)C) of wood and leaf cellulose of beech trees (Fagus sylvatica L.) was studied at 80 sites in northeastern France. We sampled sites with contrasting water balance, depending on soil type and precipitation. We tested the hypothesis that inter-site variations in plant delta(13)C reflect the spatial distribution of soil water availability, and we assessed whether delta(13)C could be used as a bioindicator of soil water availability. Patterns of variation in delta(13)C were compared with estimates of monthly water balance and with other soil characteristics. Between-site variability in delta(13)C was high (2.9 per thousand range in wood cellulose, 2.1 per thousand in leaf cellulose), but variation in water availability appeared to be only a minor factor contributing to this variation in delta(13)C. Unexpectedly, spatial variations in wood and leaf cellulose delta(13)C were significantly and positively related to soil fertility expressed by soil pH (r = 0.42 and 0.43, respectively) and cation content. On average, trees growing on acidic soils displayed 0.5 per thousand lower delta(13)C in both wood and leaf material than trees growing on neutral or calcareous soils. Our initial hypothesis of a strong negative relationship between delta(13)C and site water availability was not confirmed. In the study zone, neither wood nor leaf delta(13)C appeared to be a reliable bioindicator of spatial variations in water availability. Possible causes for the lack of a relationship are discussed. Our findings confirm, under natural conditions, the strong effect of soil fertility on water-use efficiency previously observed in experiments. This effect needs to be considered in isotopic studies involving different sites.

[Early short-term treatment of neonatal hip instability with the Pavlik harness]. / Traitement précoce et court des instabilités néonatales de hanche par harnais de Pavlik.

PURPOSE OF THE STUDY: The purpose of this work was to study early short-term treatment of reducible dislocated or very unstable dislocated hips using the Pavlik harness. This approach is based on the theory of that dislocation favors dysplasia and that spontaneous correction occurs if the hip is reduced and stable. Very easily dislocated hips have been qualified as "major instability" if voluntary dislocation was easily achieved. In this case, it is very difficult to predict whether postnatal capsuloligamentary retraction will occur in the reduced or dislocated position. MATERIAL AND METHODS: We retained for study 34 patients with 44 pathological hips; 15 hips presented reducible dislocation and 29 major instability. Treatment began early at 3.4 days of life on average and lasted 27.9 days. RESULTS: Outcome was very good for 39 hips with stabilization and spontaneous correction of the acetabular dysplasia, good in four with late correction of the dysplasia, and a failure in one. There were no major complications, none of the patients presented post-reduction osteochondritis. DISCUSSION: Two different entities can be distinguished: dislocation producing dysplasia which is symptomatic neonatally and would imply pathogenic in utero events, and primary dysplasia which can be asymptomatic at birth and for which correction is not spontaneous. If the hip is symptomatic at birth, treatment should begin immediately and be continued to confirmation that the reduced hip is stable, i.e. about three to five weeks on average. Simple dysplasia of dislocatable hips should be excluded from this strategy because of their favorable spontaneous course. Likewise for irreducible dislocated hips because of the higher risk of complications. Under these conditions, this therapeutic strategy is effective for the reduction, stability, and correction of dysplasia achieved in 97.7% of cases without increasing the rate of complications.

Complications occurring during conservative management of splenic trauma in children.

AIM: Conservative management of splenic rupture in haemodynamically stable children is now generally accepted. However, during follow-up, many complications can occur. The aim of this study was to describe the complications we observed and to propose a standardised follow-up adapted to them. METHODS: Between March 1992 and December 2002 we managed 65 children (aged between 3 and 15 years old) with accidental splenic rupture. Follow-up and treatment consisted of a 10-day bed rest with sonogram and Doppler controls on the 5th and 10th day and subsequently every month until complete healing. Complications included secondary haemorrhage in 3 cases, cystic evolution in 5 cases, and pseudo-aneurysm in 2 cases. All were treated by renewed bed rest. Three of the cysts resolved spontaneously, the other two underwent cystic resection and epiploplasty by laparotomy (n = 1) or laparoscopy (n = 1) and both pseudo-aneurysms were selectively embolised. There were no splenectomies. CONCLUSIONS: Complications essentially occurred in older children and were not related to gender, type of fracture, or extent of bleeding. Cystic evolution of the sub-capsular haematomas can appear up to 1 month after trauma. Peripheral pseudo-aneurysms which could be responsible for secondary haemorrhages were selectively embolised. We favour the use of the Doppler sonogram for follow-up until total recovery of these patients, even in low-grade traumas. Considering the number of complications encountered we do not believe the American evidence-based guidelines are suitable for our population.

Treatment of post-appendectomy intra-abdominal deep abscesses.

The treatment of acute appendicitis in children is sometimes followed by complications including intra-abdominal abscess, for which the traditional treatment is surgical drainage. We evaluated the efficacy of antibiotic management compared to classic surgical treatment. This retrospective study investigated 22 children from 5 to 13 years of age with one or many abscesses after appendectomy, treated between 1992 and 2002. Eleven received surgery and the other 11 were treated with triple antibiotherapy. The two groups were comparable. Surgery was efficient in 36% of cases and complications occurred in 64% of cases (digestive fistula, intraperitoneal abscess, gaseous gangrene and septic shock). Average hospital stay in this group was 16.7 days. In the other group, medication was efficient in 91% of cases; a recurrent abscess was operated and a residual stercolith, which was maintaining the infection, was removed. The average hospital stay in this group was 10.4 days. Medical treatment of intraperitoneal abscess seems to be effective. Hospitalisation is shorter with medical management and complications are rare. Therefore, medication may be proposed in most cases, except when there are residual foreign bodies or stercoliths. Poor patient status and septic shock are the two other contraindications, because antibiotherapy is not immediately efficient.