Amandine Rubio

A too-long anterior process of the calcaneus: a report of 31 operated cases.

A too-long anterior process of the calcaneus is one of the causes of repeated sprained ankles or painful feet in the child or adolescent that is often ignored and misdiagnosed. Among 31 cases of adolescents having consulted for these symptoms, a too-long anterior process of the calcaneus was discovered on radiographs, and explored in detail with a computed tomography scan or an MRI. The decision for surgical resection was taken considering the discomfort expressed by these children. The intraoperative observation corroborated the radiological findings and permitted a better understanding of the mechanisms responsible for the pain, the repeated sprained ankles and other instabilities. The surgical resection, which is a simple procedure, gave very good results. One must nevertheless be aware of the possible secondary lesions because of repeated sprained ankles: breakage of the lateral ligaments of the ankle and external malleolus nonunion or talus osteochondritis, which can compromise the operations result, if they are not treated simultaneously.

Percutaneous aspiration irrigation drainage technique in the management of septic arthritis in children.

BACKGROUND Septic arthritis in childhood is a therapeutic emergency. The authors present their experience using an intermediate technique with the advantages of the percutaneous aspiration irrigation drainage: joint aspiration, irrigation, and declivious drainage. METHODS All children were treated by joint aspiration under fluoroscopic control, large volume irrigation, and declivious nonsuction drainage associated with immobilization and intravenous antibiotics during 8 days to 10 days. The draining system was removed when clinical improvement (namely apyrexia) and the decrease of biological inflammatory response were obtained. A late follow-up phone interview was made for each patient. Fifty-two patients were included in this study, with a mean age of 4.3 years. The most common sites of arthritis were the hip (19 of 52, 36%) and the knee (17 of 52, 32%), but ankle (8 of 52, 15%), shoulder (12%), and elbow (3%) were also involved. RESULT Apyrexia was obtained after a mean period of 2 days. The mean draining duration was 4.5 days. On the last follow-up visit (at 21 months on average; range, 12-56 months), all patients except one were totally painless and had no limitation of physical activity. CONCLUSION Percutaneous aspiration irrigation drainage assured very good results in this study population, with rapid clinical and biological improvement and the absence of long-term sequelae. The advantages of this technique include permanent joint access and control of synovial effusions, with only one general anesthesia and minimal iatrogenic morbidity.

Noninvasive Procedures to Evaluate Liver Involvement in HIV-1 Vertically Infected Children

Objectives: Progressive liver injury is a concern in HIV-infected children exposed to long-term antiretroviral drugs and to the cytopathic effect of HIV. Yet liver biopsy is usually considered too invasive to be repeated in these patients. The aims of this study are to evaluate the feasibility of noninvasive hepatic investigations in HIV-1-infected children, assess the prevalence of signs of liver affection, and analyse the influence of the HIV disease severity and the exposure to antiretroviral therapy. Materials and Methods: A cross-sectional study conducted in 26 HIV-1 vertically infected children ages 8 to 18 years old. Liver function was assessed with standard serum biochemical markers, FibroTest, ActiTest, SteatoTest, Forns index, aspartate aminotransferase to platelet ratio index, ultrasound, and Fibroscan. Results: Nineteen (>60%) children had signs of liver affection on at least 1 of the test results: 13 (50%) had elevated liver enzymes, 15 (63%), 8 (33%), 5 (21%), and 5 (21%) had abnormal FibroTest, ActiTest, Forns index, and aspartate aminotransferase to platelet ratio index results, respectively. Four children (17%) had mild liver steatosis on ultrasound. Fibroscan measures were significantly higher in patients than in age-matched healthy children. Patients with elevated Fibroscan measures also had significantly higher FibroTest results. Age, HIV stage N in the Centers for Disease Control and Prevention classification and exposure duration to nucleoside reverse transcriptase inhibitor and non-nucleoside reverse transcriptase inhibitor drugs were the main risk factors for hepatotoxicity. Conclusions: More than half of our population of HIV-infected children had biological and/or radiological signs of liver affection. Regular follow-up of liver function is necessary in these patients, which is now possible with noninvasive procedures.

Residual hip growth after pinning of slipped capital femoral epiphysis.

Screwing of slipped capital femoral epiphysis must prevent its further slipping by prematurely fusing the physis. Whichever material is used, persistent femoral growth has been described, thereby increasing the risk of bone deformation. The objective of this study is to evaluate the residual growth after screwing of slipped capital femoral epiphysis. This study concerned 26 children, among which 13 children have been included, and 13 children excluded because of an incomplete clinical or radiological follow-up, or treatment by another technique. The pathological hip was treated with one screw (in eight cases) or two screws (in five cases). The controlateral hip was fixed with one screw. The different measures were taken on anteroposterior radiographs done the days after surgery, and on the first radiograph on which the growth plate had fused. Growth plate fusion was obtained after an average of 20 months. Each patient had presented a residual growth of at least one hip, thus 85% of the 26 fixed screws. Among the four hips, which did not grow, three were pathological, and were fixed by one screw (in one case) or two screws (in two cases), in a central or medial position. There was not any statistical relationship between the growth persistence and the other studied criteria. These results, proving the growth persistency, suggest that the follow-up must be extremely careful, as the number of threads crossing the growth plate will decrease, with the risk of loss of mechanical stability and reappearance of the femoral epiphysis slippage.

Systematic percutaneous pinning of displaced extension-type supra-condylar fractures of the humerus in children: a prospective study of 67 patients

Extension supra-condylar fracture of the humerus is a most common fracture in children. Several treatment regimens have been used in the treatment of displaced supra-condylar humeral fractures. A prospective study was performed including 67 children presenting a displaced supra-condylar humeral fracture. We uniformly treated them by closed reduction under general anaesthesia with fluoroscopic control and two parallel lateral pinnings. The criteria for inclusion were a supra-condylar humeral fracture (Gartland type II and type III) with posterior displacement in an infant, or in an adolescent less than 16 years old. According to the Flynn classification, there were 47 excellent results (70%), 15 good (23%), two fair (3%) and three poor (4%), which means 62 good and excellent results (93%). This percentage fell to 61 and 27% respectively if we considered the humero-ulnar angle. Forearm prono-supination was always normal. Poor results analysis found no relation between them except for the type of the fracture. The humero-ulnar angle seemed to be the pejorative radiological criterion. There was no correlation between type of reduction in AP or lateral X-ray and functional or cosmetic results. Poor fracture reduction induced residual deformity; anatomic reduction is therefore necessary to avoid it.RésuméLa fracture supra-condylienne de l’humérus est une des fractures les plus fréquentes chez l’enfant. Plusieurs méthodes thérapeutiques sont utilisées pour les fractures déplacées. Nous avons réalisé une étude prospective incluant 67 enfants présentant une fracture supra-condylienne déplacée de l’humérus. Toutes ces fractures ont été traitées par une réduction par manoeuvres externes sous anesthésie générale et amplificateur de brillance, associée à une fixation par brochage percutané selon la technique de Judet. Nous avons inclus dans cette étude toutes les fractures supra-condyliennes avec un déplacement postérieur (type II et III de Gartland) chez un enfant ou un adolescent âgé de moins de 16 ans. Selon la classification de Flynn, il y a 47 excellents résultats (70%), 15 bons (23%), 2 moyens (3%) et 3 mauvais (4%), soit 62 bons et excellents résultats (93%). Ce pourcentage n’est que, respectivement, de 61% et de 27% si l’on considère la mesure de l’angle huméro-radial. La prono-supination de l’avant-bras est toujours normale. L’analyse des mauvais résultats ne retrouve pas de facteurs prédisposants excepté le type de fracture. L’angle huméro-radial est un critère important car le cubitus varus est péjoratif. Il n’y a pas de corrélation entre les critères radiologiques de réduction et le résultat fonctionnel ou cosmétique.

Is the renin-angiotensin system actually hypertensive?

The historical view of the renin–angiotensin system (RAS) is that of an endocrine hypertensive system that is controlled by renin and mediated via the action of angiotensin II on its type 1 receptor. Numerous new angiotensins (Ang) and receptors have been described, the majority being hypotensive and natriuretic, namely Ang-(1-7) and its receptor rMas. Renin and its precursor (pro-renin) can bind their common receptor. In addition to the production of Ang II, this receptor triggers intracellular effects. Given the control of renin production by intracellular calcium, calcium homeostasis is of particular importance. Ang-(1-12), which is not controlled by renin, is converted to several different angiotensin peptides and is a new pathway of the RAS. Local RAS enzymes produce or transform the different hyper- or hypotensive angiotensin within vessels and organs, but also in blood through circulating forms of the enzymes. In the kidney, a powerful local vascular RAS allows for the independence of renal vascularization from systemic control. Moreover, the kidney also contains an independent urinary RAS, which counterbalances the systemic RAS and coordinates proximal and distal sodium reabsorption. The systemic and local effects of renal RAS cannot be analyzed without taking into account the antagonistic effect of renalase. Our concept of RAS needs to evolve to take into account its dual potentiality (hyper- or hypotensive).

Pulmonary Function in HIV-1 Vertically Infected Children

Background: Despite reports of an increasing incidence of asthma in HIV-infected children, exploration of pulmonary function by spirometry has never been reported in this population in the HAART era. Objective: The aim of this study was to determine the prevalence of spirometric abnormalities in HIV-1 infected children. We conducted a cross-sectional study of pulmonary function tests (PFT) in HIV-1 vertically infected children. Methods: Spirometric values were measured in 17 HIV-1 chronically infected children and compared to matched healthy children. In HIV-1 infected children, the correlations between PFT and the determination of the single breath carbon monoxide diffusing capacity of the lung (TL CO ) and immunological and virological values were assessed. Results: Overall, 11 of the 17 PFT were normal. Four showed mild distal obstruction. Two were considered restrictive. When compared with matched healthy children, the only difference was the FEV1/FVC ratio that was significantly lower in the patients’ group (91.9% of predicted value versus 97.1%, p<0.0001). We found a positive correlation between TL CO and the CD4/CD8 T-cell ratio (p=0.012) and viral load (p=0.05). We observed that FEF 25-75 values increased with age and weight in healthy children (p= 0.006 and p=0.007 respectively), but not in infected patients. Conclusions: Our results showed that chronic HIV-1 infection and/or continuous HAART exposure induce a specific response of the pulmonary immune system which may compromise its function with time. If confirmed, it may justify a careful follow-up of pulmonary function in vertically infected children

Real Life HAART Efficacy in Chronically HIV-1 Infected Children 15-Year Follow-Up

Background: It is now widely accepted that the antiretroviral first line-treatment basis in HIV-1 infected children is a combination of 2 nucleoside reverse transcriptase inhibitors and 1 protease inhibitor or 1 non NRTI. However, after few months or years, some patients presented with virological failure. Objective: Using a “real life conditions” cohort, we aimed to study the median duration of Viral Controlled Replication (VCR) and the factors associated with failure in infected children. Methods: Thirty six HIV-1 infected patients were followed between September 1996 and September 2010. Children were included starting from the date of initiation of their first successful HAART. Duration of effective VCR was defined as a length, in months, from inclusion to virological failure defined as a HIV-1 PCR-RNA higher than 400 c/ml. Results: The overall median VCR duration was 46.2 months. Duration was significantly shorter in patients: previously exposed to mono therapies, with CD4 count lower than 350 and with PI-based HAART. After adjustment, the negative effect of PI-based HAART regimen compared to nNRTI-based HAART remained significant (HR=5.7 [95%CI=1.43-22.7]). Conclusion: Therefore, retrospective analysis of “real life” condition data in observational cohort may contribute to a better understanding of non optimal virological care.

Transient elastography (Fibroscan) in HIV-1 vertically infected children. A cross-sectional study

Progressive liver toxicity is a concern in HIV-infected patients. Although liver biopsy remains the gold standard for liver assessment, its invasiveness, sampling errors, variability in interpretation and expense do not make it an ideal routine follow-up exam. During the last decade, new non-invasive tools have been developed for the assessment of hepatic fibrosis in HCV and HIV/HCV co-infected patients.