Coronal STIR MRI sequences in unexplained limping in children under 6 years old: A single-center retrospective study of 130 cases.

INTRODUCTION: Limping is a common presenting symptom in young children. Clinical examination backed up by laboratory analysis, standard radiography, and/or ultrasound may fail to determine the diagnosis, and limping may prove persistent, requiring repeated consultation. Magnetic resonance imaging (MRI) can suggest the etiology or provide welcome reassurance when normal. We advocate the use of MRI in cases of persistent unexplained limping in young children. The study hypothesis was that coronal short TI inversion recovery (STIR) MRI has good negative predictive value (NPV) in unexplained limping in children under 6 years of age. MATERIAL AND METHOD: Coronal STIR MRI sequences were analyzed in 130 children younger than 6 years (84 boys, 46 girls) during the period April 2007 to May 2017. They extended from the lower thoracic spine down to the feet. Agreement was analyzed between the radiologist's initially suggested diagnosis and the pediatric orthopedic specialist's final diagnosis. RESULTS: Overall, 49 scans were normal (37.7%) and 81 abnormal (62.3%). The mean age at MRI was 32.3 months. Coronal STIR MRI had 98% NPV. There was 99.2% agreement between the radiologist's diagnosis and the final diagnosis. DISCUSSION: The recently reported contribution of STIR MRI in bone and joint infections was extended to unexplained limping. CONCLUSION: First-line MRI with coronal STIR sequences improved the diagnostic efficacy, thanks to its speed and relative lack of movement artifacts.

Trampoline injuries compared with other child activities.

INTRODUCTION: Trampolines are responsible for specific injuries. We examined the severity of these injuries in children compared with those occurring in other activities. Our primary goal was to compare the injury severity between trampolining and other activities. Our secondary goal was to evaluate risk factors for severity in order to establish preventative measures and, third, to evaluate the increased prevalence of these injuries in our hospital from 2008 to 2016. MATERIAL AND METHODS: Our study was a retrospective, comparative, descriptive, and epidemiological research. Children aged 2-15 years admitted to our traumatology emergency services between June and October 2016 were included in the study. Non-sport-related injuries were excluded. Serious injuries were classified as fractures and admissions to the operating room. RESULTS: In total, 1106 children were admitted including 107 trampoline accidents. The fracture rate was similar in the two groups: 34 (31.78%) vs. 309 (30.93%), OR=1.039, 95% CI [0.65, 1.62] P=0.91. Surgical treatments were more frequent in the trampoline group: 4 (3.74%) vs. 18 (1.80%) OR=2.114, 95% CI [0.51, 6.58] P=0.156. Several people jumping simultaneously on the trampoline was a risk factor (OR=1.56, 95% CI [1.0908, 2.308], P=0.018). Parental supervision was a protective factor (OR=0.271, 95% CI [0.08, 0.80], P=0.023). Trampolining accidents were 9.7 times more common in our center in 2016 compared with 2008. DISCUSSION: To our knowledge, no study has compared trampoline injuries with those stemming from other activities. Awareness campaigns are needed as well as information from sellers, who have to be trained. CONCLUSION: Surgical treatments are twice as likely in trampoline accidents. Prevention is simple: Children should be alone on the trampoline and supervised by an adult.

ACL reconstruction in 11 children using the Clocheville surgical technique: Objective and subjective evaluation.

INTRODUCTION: The over-the-top position of the femoral metaphyseal tunnel during extraphyseal ligament reconstruction of the anterior cruciate ligament (ACL) according to Clocheville may be responsible for negative anisometry. Until now, the follow-up of children operated using this pediatric technique was limited to screening for iatrogenic epiphysiodesis and the search for postoperative clinical instability. The objective of this study was to measure residual laxity using objective tests, to quantify muscle recovery, and to evaluate the quality of life of these patients in terms of the sports activities. MATERIAL AND METHODS: Eleven patients with a mean age of 13.5years were seen at a mean 2.1years of follow-up. They underwent objective clinical tests (GNRB(®) arthrometer and CON-TREX(®) dynamometer) as well as subjective questionnaires (IKDC and KOOS). RESULTS: No significant difference was found between the healthy knee and the operated knee for either the GNRB(®) at 134N (P=0.79) or at 200N (P=0.98). The CON-TREX(®) system allowed us to measure a median percentage of quadriceps recovery of 80.7% (range, 52.2-114.5) in terms of muscle power (60°/s) and 81.2% (range, 51.6-109.6) for muscle response (180°/s). The median subjective IKDC score was 94.73/100 (range, 73.68-98.93); 72.7% of the patients resumed competitive sports. DISCUSSION: This study's lack of statistical power did not show a significant difference in terms of residual laxity at rest of GNRB(®) transplants, while a mean differential of +0.4mm was observed. Although pediatric transphyseal ligament reconstruction techniques are increasingly used, the Clocheville technique remains, in our opinion, an attractive surgical alternative in the youngest subjects, with no major risk of iatrogenic epiphysiodesis even though it is theoretically anisometric. LEVEL OF EVIDENCE: IV.

L5S1 spondylolisthesis in children and adolescents.

The precise etiology of childhood and adolescent spondylolisthesis (SPL) remains undetermined, but would seem to be multifactorial, deriving from anthropological adaptations of spinal sagittal balance combined with microtraumatic, genetic and dysplastic factors. Description of sagittal parameters not only lends weight to etiopathogenetic hypotheses, but also seeks to improve the classification of severity so as to optimize treatment according to clinical and radiological presentation. Thus, surgery should not only stabilize the lumbosacral junction by solid fusion but also correct pelvic abnormalities so as to restore overall sagittal balance in the long-term, without requiring spinal, pelvic or sub-pelvic compensation and with the lowest possible energy cost. Methods are still under debate; surgical technique, whether instrumental or not and whether aiming at in situ fusion or to correct lumbosacral deformity, all incur neurological risk of which child and family should be informed. Only long-term follow-up of functional results on quality-of-life scales, combined with radiological results for surgery aiming at lumbosacral angle correction, will be able to demonstrate superiority over in situ fusion surgery.

[Peroneal nerve palsy in children: Uncommon diagnosis of a proximal tibiofibular synovial cyst]. / Paralysie du nerf fibulaire commun : diagnostic rare chez l'enfant d'un kyste synovial tibio-fibulaire supérieur.

Compression of the common peroneal nerve by synovial cysts of the tibiofibular joint is a rare disease. Two macroscopic forms may be encountered: extraneural cysts and intraneural cysts. In a review of the literature, we found only three pediatric cases of common peroneal nerve palsy due to extraneural cysts and about 60 cases reported in adults. Taking advantage of the clinical history of two children operated in our department for this disease, we describe this uncommon entity, which must be diagnosed and treated rapidly. Even in the presence of severe clinical and electrophysiological symptoms, a full clinical recovery is possible, as observed in these two children. However, follow-up is needed because recurrence is possible.

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.

Minimally invasive harvesting of nonvascularized fibular graft in children.

Using a nonvascularized fibular graft is part of the therapeutic arsenal for filling bone loss defects. It is conventionally performed by open surgery. The authors propose a minimally invasive technique for harvesting a free fibular graft. The fibula was removed subperiosteally by two or three small incisions in five patients with a mean age of nine years and nine months. The mean surgical time was 21 min and 40.5% of the length of the fibula was harvested. At the donor site, we found no removal-related complications, regeneration of the fibula was observed in 80% of cases, and the cosmetic result was considered excellent by all patients with a mean 4.3 years follow-up. This minimally invasive technique is simple and fast, with very low morbidity in our experience.

Monopolar-probe monitoring during spinal surgery with expandable prosthetic ribs.

BACKGROUND: Intraoperative monitoring (IOM) has been proven to decrease the risk of neurological injury during scoliosis surgery. The vertical expandable prosthetic titanium rib (VEPTR) is a device that allows spinal growth. However, injuries to the spinal cord and brachial plexus have been reported after VEPTR implantation in 2 and 5% of patients, respectively. Simultaneous monitoring of these two structures requires the use of multiple time-consuming and complex methods that are ill-suited to the requirements of paediatric surgery, particularly when repeated VEPTR lengthening procedures are needed. We developed a monopolar stimulation method derived from Owen's monitoring technique. This method is easy to implement, requires only widely available equipment, and allows concomitant monitoring of the spinal cord and brachial plexus. The primary objective of this study was to assess the reliability of our technique for brachial plexus monitoring by comparing the stability of neurogenic mixed evoked potentials (NMEPs) at the upper and lower limbs. HYPOTHESIS: We hypothesised that the coefficients of variation (CVs) of NMEPs were the same at the upper and lower limbs. MATERIAL AND METHODS: Twelve VEPTR procedures performed in 6 patients between 1st January 2012 and 1st September 2014 were monitored using a monopolar stimulating probe. NMEPs were recorded simultaneously at the upper and lower limbs, at intervals of 150 s. The recording sites were the elbow over the ulnar nerve and the popliteal fossa near the sciatic nerve. Wilcoxon's test for paired data was used to compare CVs of the upper and lower limb NMEPs on the same side. RESULTS: Mean CV of NMEP amplitude at the lower limbs was 16.34% on the right and 16.67% on the left; corresponding values for the upper limbs were 18.30 and 19.75%, respectively. Mean CVs of NMEP latencies at the lower limbs were 1.31% on the right and 1.19% on the left; corresponding values for the upper limbs were 1.96 and 1.73%. The risk of type I error for a significant difference between the upper and lower limbs was 0.5843 on the right and 0.7312 on the left for NMEP amplitudes and 0.7618 on the right and 0.4987 on the left for NMEP latencies. CONCLUSION: Using an epidural active electrode and a sternal return electrode allows simultaneous stimulation of the cervical spinal cord and brachial plexus roots. The NMEPs thus obtained are as stable (reliable) at the upper limbs as at the lower limbs. This easy-to-implement method allows simultaneous monitoring of the upper and lower limbs. It seems well suited to VEPTR procedures. LEVEL OF EVIDENCE: IV, retrospective single-centre non-randomised 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.

Hereditary sensory and autonomic neuropathy type IV and orthopaedic complications.

Hereditary sensory and autonomic neuropathy type IV (HSAN-IV) is a very rare autosomal recessive disorder characterized by recurrent episodes of unexplained fever, extensive anhidrosis, total insensitivity to pain, hypotonia, and mental retardation. The most frequent complications of this disease are corneal scarring, multiple fractures, joint deformities, osteomyelitis, and disabling self-mutilations. We reported the case of a 12-year-old boy. The goal was to discuss our decision-making and compare this case with cases described in the literature.

Percutaneous hallux valgus surgery in children: short-term outcomes of 33 cases.

BACKGROUND: Many surgical procedures for hallux valgus correction have been reported, including percutaneous techniques. In children, the risk of recurrent hallux valgus after any type of surgical correction seems to deserve attention. To our knowledge, no studies have investigated the outcomes of percutaneous hallux valgus surgery in children. Here, we report a study on this topic. MATERIALS AND METHODS: We retrospectively reviewed 33 percutaneous surgical procedures to correct idiopathic hallux valgus in 18 children younger than 16 years of age. Radiographs obtained pre-operatively and at last follow-up were used to determine the hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA). Clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and a satisfaction score. RESULTS: Mean follow-up was 30 months. At surgery, mean age was 12.5 years and the growth plates were open in 20/33 (61%) cases. Mean HVA correction was 8.6° (from 28.06° to 19.45°, P<0.01) and mean DMAA correction was 7° (from 15.97° to 8.97°, P<0.01). At last follow-up, 20 (61%) feet had HVA values greater than 16°, but in half these cases the patients reported being satisfied with the procedure, leaving 30% of feet with symptomatic under-correction. Mean post-operative AOFAS score was 80.7. Patients were satisfied or very satisfied for 24/33 (73%) feet. DISCUSSION: We found a high-rate of radiographic under-correction. Studies of factors associated with recurrent hallux valgus would be expected to result in technical improvements and therefore in better outcomes. CONCLUSION: Our evaluation of short-term outcomes after percutaneous hallux valgus surgery without internal fixation showed both a high-rate of under-correction and a high-rate of patient satisfaction. Medium-term studies are needed to determine whether these results are sustained over time. The available data suggest a number of technical improvements. At present, we plan to continue to offer this procedure to children and their families. LEVEL OF EVIDENCE: Level IV, retrospective study.

[Thoracic outlet syndrome in a child: a rare pediatric diagnosis]. / Syndrome du défilé thoraco-brachial par côte surnuméraire : un diagnostic rare en pédiatrie.

Thoracic outlet syndrome (TOS) is a rare pediatric syndrome and few cases have been reported in the literature. The authors report the case of a 10-year-old boy with generalized arm pain and neck stiffness. The angiocomputed tomography revealed the presence of a TOS caused by an additional cervical rib and stenosis of the sub-clavian artery. The resection of this rib relieved the patient of his pain during a full year following surgery. This case reminds us that children can also be affected by TOS. When a cervical rib causes TOS, a resection is often necessary.

Pubo-femoral distance: an easy sonographic screening test to avoid late diagnosis of developmental dysplasia of the hip.

OBJECTIVES: To propose an easy and reproducible sonographic screening test able to avoid late presentation of developmental dysplasia of the hip (DDH). METHODS: The pubo-femoral distance (PFD) cut-off point was determined on 980 infants who underwent ultrasonography of the hips in comparison with the final diagnosis, based on clinical, ultrasound data and follow-up. PFD reproducibility was tested on 52 hips by both an experienced and an inexperienced radiologist. After teaching this screening method to general radiologists, its impact was evaluated by analysing the rate of late diagnosis in an entire administrative area. RESULTS: An abnormal PFD threshold above 6 mm gave a sensitivity of 97.4 % for the diagnosis of DDH (271 hips) and a specificity of 84 %. Sensitivity increased to 100 % when taking into consideration children of 1 month or older. The PFD measurement stayed reproducible even in inexperienced hands (k = 0.795). For 3 years, following the extension of screening to all female infants, there was no late diagnosis of DDH in girls in amongst a catchment area of 1 million inhabitants. CONCLUSIONS: PFD measurement with a threshold for abnormality of 6 mm at the age of 1 month, without asymmetry above 1.5 mm, could eradicate DDH late diagnosis.

Neuro-orthopaedic evaluation of children and adolescents: a simplified algorithm.

Orthopaedic surgeons are often the first physicians to evaluate paediatric patients in the event of delayed walking, gait abnormalities, or parental concern about motor abilities. Therefore, orthopaedic surgeons must be thoroughly familiar with the normal neurodevelopmental stages. Neurological disorders are often first recognised during an orthopaedic evaluation. Minimal neurological abnormalities should be taken as warning signs that require additional investigations. Consequently, the evaluation must follow a strict protocol, even in children referred for apparently trivial functional disorders. We have developed an original physical examination protocol in which the largest possible number of signs is sought in each body position to ensure that the examination is both systematic and rapid. About ten minutes are required when all findings are normal. This protocol is extremely helpful for identifying the cause of the problem that motivated the evaluation or for reassuring the child and family. The main causes of paediatric orthopaedic disorders are cerebral palsy, spinal dysraphism, myopathies, peripheral neuropathies, motor neuron diseases, and intraspinal tumours. In some instances, no definitive diagnosis can be established clinically. In this situation, appropriate orthopaedic treatment can be initiated, although considerable caution is in order when establishing the indications. The cause may be detected only much later, when the clinical manifestations become more prominent.

Idiopathic club foot treated with the Ponseti method. Clinical and sonographic evaluation of Achilles tendon tenotomy. A review of 221 club feet.

The Ponseti method applied to treating idiopathic club foot consists in placing successive corrective casts, possibly an Achilles tendon tenotomy, then derotation braces, a method that has proven its efficacy. This study compared 221 cases of club foot treated with this method between 2002 and 2007 divided into two groups, based on whether or not Achilles tendon tenotomy was performed. Assessment was both clinical and sonographic. We observed clear improvement of the results in the group that underwent Achilles tendon tenotomy and a significant difference in the rate of secondary surgery. The sonographic evaluation also showed improvement of the morphological results. We now systematically propose Achilles tendon tenotomy however severe club foot may be.

Discoid meniscus associated with agenesis of the anterior cruciate ligament in an 8-year-old child.

Among the congenital anomalies involving the lateral compartment of the knee, the combination of both a discoid meniscus and agenesis of the anterior cruciate ligament (ACL) is extremely rare and probably underestimated due to the presence of a meniscofemoral ligament often mistaken for an intact ACL. The therapeutic management of such abnormalities is not univocal and highly depends on their clinical impact. We report on the observations of an 8-year-old boy presenting with a cystic formation on a lateral discoid meniscus associated with agenesis of the ACL and the presence of an anterior lateral meniscofemoral ligament.

Irreducible developmental dysplasia of the hip due to acetabular roof cartilage hypertrophy. Diagnostic sonography in 15 hips.

INTRODUCTION: Irreducible developmental dysplasia of the hip (DDH) in newborns is a rare entity. The different obstacles preventing reduction have been described in the literature. HYPOTHESIS: A clinical form of DDH with hypertrophy of the cartilage of the acetabular roof (acetabular bulge) can be reliably identified on ultrasound and should probably be defined as a separate entity. MATERIALS AND METHODS: For the first time, the authors report their experience, a review of the literature and the radiographic description (ultrasound, arthrography MRI) of irreducible neonatal DDH due to hypertrophy of the cartilage of the acetabular roof (acetabular bulge) in 12 infants (15 hips). RESULTS: Neonatal sonography seems to be sufficient to identify this specific clinical entity without any additional work-up. This sonographic sign could help determine the therapeutic strategy earlier in this severe and complex form of DDH.

[Developmental dysplasia of the hip]. / Luxation congénitale de hanche chez l'enfant.

At one month, the acetabular depth from a standard lateral coronal section is 4.6 ± 1.0mm. The correlation between experienced and junior radiologists is high (kappa 0.795). A treshhold of 6mm with a Δ (difference between right and left) less than 1.5mm provides a sensitivity of 100% for the detection of DDH at one month. Universal US screening at one month of all high-risk infants in 2009 resulted in a reduction of delayed diagnosis of DDH (zero girls, two boys) in Ille-et-Vilaine due to continuous medical education of general radiologists.

Applications in spinal imbalance.

The pelvis may be seen as a single vertebra, between the spine and the femurs. The anatomy of this pelvic vertebra has changed with the evolution of species, notably with the transition to bipedalism, with the consequent appearance of lumbar lordosis. The lumbosacral angle, almost non-existent in other mammals, is at its greatest in humans. Pelvic and spinal radiological parameters reflect the sagittal balance of the spine in bipedal humanity. Applications in the management of spinal imbalance are numerous. Arthrogenic or degenerative kyphosis is the stereotypic example of spinal aging. Postoperative flat back following spine surgery is hard to prevent. Scoliosis surgery in adults should now take greater account of the patient's individual sagittal balance, by analyzing the pelvic and spinal parameters. The extent of arthrodeses performed during adolescence to manage idiopathic scoliosis may also induce problems of balance in adulthood if these elements are not taken into account.