Lateral hemiepiphysiodesis of the first metatarsal for juvenile hallux valgus.

BACKGROUND: Juvenile hallux valgus (JHV) frequently results in an impaired quality of life because of pain and deformity. We used a validated clinical score to investigate the efficacy of lateral hemiepiphysiodesis of the first metatarsal base as a treatment for JHV. METHODS: We conducted a prospective, nonrandomized, single center cohort study of children who underwent lateral hemiepiphysiodesis for 31-IV, with a clinical and radiologic follow-up of at least 2 years. The efficiency of the procedure was assessed with the Hallux Metatarsophalangeal Interphalangeal Scale (HMIS), the metatarsophalangeal angle (MPA), and intermetatarsal angle (IMA). RESULTS: Twelve patients (22 feet) with JHV were treated by lateral hemiepiphysiodesis between 2012 and 2015. Average age at surgery was 10 years, and average follow-up was 3.5 years. The average HMIS score increased from an average of 56 at baseline, to 92 at last follow-up ( p < 0.01). The average IMA decreased by 2°, from 13° preoperatively to 11° postoperatively. Average MPA decreased from 26° at baseline to 22° after surgery. No complications occurred in the immediate postoperative period, and no patient needed an additional procedure. CONCLUSION: The HMIS score was significantly improved after lateral hemiepiphyslodesis, with a clear improvement in pain and functional impairment at last follow-up. We noted a stabilization of the IMA and MPA, but the radiologic benefit did not reach statistical significance. Our data support the use of lateral hemiepiphysiodesis as an effective and safe treatment of JHV.

More than just teddy bears: Unconventional transmission agents in the operating room.

INTRODUCTION: Surgical site infection (SSI) following orthopedic surgery can have a substantial impact on patients and families. The rate remains high, ranging from 0.5% to 8.5% in pediatric spine surgery. It is common to allow children to bring a teddy bear (or similar toy) to the surgical ward to help reduce the stress of surgery. We hypothesize that despite their known benefits for children, teddies would increase the bacterial load in the surgical room. METHODS: A blinded descriptive study was conducted from June 2015 to September 2016. The study included children entering the hospital through the emergency ward for a traumatic cause requiring surgery. Patients admitted for infectious problems and those who had been hospitalized less than 6 months before the inclusion date were excluded. A picture of the teddy was taken and stored in a blind fashion. The AFNOR (Association française de normalisation) standardized rules for bacteriological surface control and the ISO/DIS 14698 protocol were strictly followed. Two independent observers performed blind bacteriologic analyses of the teddy bears with bacteria identification and colony counts. Photos of the teddy bears were then analyzed by two blinded, independent observers: one doctor and one parent from outside the hospital. Cleanliness and fluffiness of the toy was evaluated using a numeric scale. RESULTS: Bacteria were identified on 100% of the 53 teddies included. The mean number of bacteria was 182.5±49.8 CFU/25 cm2. Eight teddies (15.1%) tested positive for potential pathogenic bacteria (two staphylococcus aureus, one acinetobacter ursingii, four acinetobacter baumannii, one pseudomonas stutzeri). Three teddies (5.7%) tested positive for fungi. The median cleanliness score was 2 (interquartile range (IQR)=1) if rated by the doctor and 2 (IQR=1) if rated by the parent. No statistical difference was found between these two values in the global teddy bear population. We found no any statistical link between the number of CFUs and the cleanliness scores given by the doctor. The median fluffiness score given by the parent was 2 (IQR=1). Looking at the correlative CFUs, we found a statistically significant difference between each stage of fluffiness with a higher stage showing higher CFU (P<0.0001). CONCLUSION: Despite their documented benefits for the child, teddy bears are not appropriate in the surgical room.

Lower-limb lengths and angles in children older than six years: Reliability and reference values by EOS® stereoradiography.

BACKGROUND: Lower-limb alignment in children is classically assessed clinically or based on conventional radiography, which is associated with projection bias. Low-dose biplanar radiography was described recently as an alternative to conventional imaging. The primary objective of this study was to assess the reliability of length and angle values inferred from 3D reconstructions in children seen in everyday practice. The secondary objective was to obtain reference values for goniometry parameters in children. HYPOTHESIS: 3D reconstructions can be used to assess the lower limbs in children. MATERIAL AND METHODS: The paediatric reliability study was done in 18 volunteers who were divided into three groups based on whether they were typically developing (TD) children, had skeletal development abnormalities, or had cerebral palsy. The reference data were obtained in 129 TD children. Each study participant underwent biplanar radiography with 3D reconstruction performed by experts and radiology technicians. Goniometry parameters were computed automatically. Reproducibility was assessed based on the intra-class coefficient (ICC) and the ISO 5725 standard (standard deviation of reproducibility, SDR). RESULTS: For length parameters, the ICCs ranged from 0.94 to 1.00 and the SDR from 2.1 to 3.5mm. For angle parameters, the ICC and SDR ranges were 0.60-0.95 and 0.9°-4.6°, respectively. No significant differences were found across experts or radiology technicians. Age-specific reference data are reported. DISCUSSION: These findings confirm the reliability of low-dose biplanar radiography for assessing lower-limb parameters in children seen in clinical practice. In addition, the study provides reference data for commonly measured parameters. LEVEL OF EVIDENCE: IV.

Outcomes of Gartland type III supracondylar fractures treated using Blount's method.

BACKGROUND: Supracondylar fractures of the elbow with major displacement are usually treated by surgical pinning and less often non-operatively as described by Blount. The objective of this study was to assess the clinical and radiological outcomes of Gartland type III supracondylar fractures treated at least 3 years earlier using Blount's method. HYPOTHESIS: Blount's method produces good outcomes after more than 3 years when used to treat Gartland type III supracondylar fractures of the humerus. METHODS: A single-centre retrospective study was done in paediatric patients who were seen within 24hours after sustaining a Gartland type III supracondylar fracture then re-evaluated at least 36 months after treatment. Closed reduction was performed either in the operating room under general anaesthesia or in the radiology suite under procedural sedation. The upper limb was then immobilised for 4 weeks using the cuff-and-collar method described by Blount (mean elbow flexion, 134°). The child was evaluated and radiographs obtained at the outpatient clinic on days 7 and 14. Functional outcomes were assessed using the 1962 SoFCOT criteria and Flynn's criteria and the radiological outcome using Baumann's angle, the humero-condylar angle, and distal fragment rotation. From 2009 to 2013, 22 patients met the inclusion criteria. Mean follow-up was 57 months. RESULTS: Clinical outcomes assessed using the 1962 SoFCOT criteria were very good in 15 patients and good in the remaining 7 patients. The rate of satisfactory outcomes according to Flynn's criteria was 100%. At last follow-up, mean Baumann's angle was 68°, mean humerocondylar angle was 42°, and 2 patients had residual rotation of the distal fragment. CONCLUSION: This work confirms the effectiveness of Blount's method for treating Gartland type III supracondylar fractures. We advocate routine first-line treatment of these fractures using Blount's method in the absence of vascular compromise and instability. LEVEL OF EVIDENCE: IV, retrospective study.

Initial treatment of congenital idiopathic clubfoot: Prognostic factors.

BACKGROUND: The initial treatment of congenital idiopathic clubfoot (CIC) is nonoperative. Either the French physiotherapy method or the Ponseti casting method may be used. Whether either method is superior over the other remains unclear. However, the method used initially is not the only determinant of the final outcome. OBJECTIVE: The primary objective was to identify determinants of the final outcome as evaluated based on the need for surgical treatment and on the Ghanem-Seringe score. HYPOTHESIS: Factors associated with the final outcome can be identified. METHODS: Between 2004 and 2011, 100 CICs in 79 patients were treated in two centres, 47 using the French method and 53 the Ponseti method. The Dimeglio grade was determined at baseline and the Ghanem-Seringe score at last follow-up. Surgical procedures (if any), splinting duration, and rehabilitation therapy duration were recorded. The two groups showed no statistically significant differences for Dimeglio grade distribution, time from birth to treatment initiation, or mean follow-up. RESULTS: Factors significantly associated with a poor outcome by univariate analysis were use of the Ponseti method (P=0.0027), older age at last follow-up (P=3×10-4), initial Dimeglio grade (P=7×10-5), and need for surgery (P=10-5); no significant effect was found for splinting duration, rehabilitation duration, bilateral involvement, or antenatal diagnosis. By multivariate analysis, factors independently associated with a poor prognosis were older age at last follow-up, Dimeglio grade, and need for surgery. CONCLUSION: This study confirms the major prognostic significance of initial severity (Dimeglio grade) on the final outcome. The data do not firmly establish that one method is superior over the other. Nevertheless, the need for percutaneous Achilles tenotomy with the Ponseti method leads us to prefer the French physiotherapy method. LEVEL OF EVIDENCE: IV, retrospective study.

Too-long calcaneal process: Results of surgical treatment and prognostic factors.

INTRODUCTION: The too-long anterior process (TLAP) can be responsible for ankle pain or repeated sprains in children or adolescents. The objective of this study was to assess the results of TLAP surgical treatment and to analyze influencing factors in case of this surgery's failure. MATERIAL AND METHODS: Retrospective single-center study conducted from 2009 to 2012 including all patients under 18 years of age for a TLAP with follow-up equal to or longer than 1 year. The results of surgical treatment were assessed using the AOFAS score. Failure was defined as no significant improvement in the AOFAS score at the last follow-up. HYPOTHESIS: Predictive factors of the result of surgical treatment for TLAP can be identified. RESULTS: At the mean follow-up of 2.5 years, 35 patients (43 feet) fulfilled the inclusion criteria. Thirteen feet (30%) presented surgical failure. According to the AOFAS score, the results were excellent in 30 feet (70%), good in four (9%), fair in five (12%), and poor in four (9%). Surgical failure was influenced by the patient's age at the onset of symptoms and at the time of surgery, the degree of functional limitation, the duration of symptoms before surgery, the number of sprains, and gender (P<0.05). CONCLUSION: Firstly, in this pediatric population with its high functional demand, the overall rate of failure of TLAP surgery was 30%. Secondly, the factors associated with failure demonstrated made it possible to identify the ideal patient for this surgery: male, with symptom onset between 7 and 10 years of age, who had experienced fewer than 15 sprains, and undergone surgery in the 3 years following the beginning of symptoms. LEVEL OF EVIDENCE: IV.

Melanotic neuroectodermal tumor of infancy: case report and review of the literature.

Melanotic Neuroectodermal Tumor of Infancy (MNTI) is a rare but distinct neoplastic entity in infancy. Diagnosis is usually made before the age of 12 months. The common clinical presentation is a rapidly growing mass of the pre-maxillary area. Its surface is unevenly pigmented. To affirm the diagnosis a biopsy is necessary. Few cases of malignancy have been described (5% of cases). Adequate surgical excision is the treatment of choice. Recurrence rate is about 10 to 15% within 5 years. We report in this article the case of a newborn with MNTI illustrating that an R0 surgical excision can be correlated to a favourable prognosis. In this case the 5 years follow up didn't show any local or distant recurrence.