B. de Courtivron

The progression of lumbar curves in adolescent Lenke 1 scoliosis and the distal adding-on phenomenon.

INTRODUCTION The postoperative deterioration of the curve below spinal fusion instrumentation resulting in a distal adding-on (AO) phenomenon in idiopathic adolescent scoliosis (IAS) frequently requires surgical revision with disappointing secondary clinical results. HYPOTHESIS Analysis of AP (coronal) range of motion (cROM) and lateral (sagittal) range of motion (sROM) on dynamic (side-bending, flexion, extension) X-rays to determine the choice of the lowest instrumented vertebra (LIV) can help reduce distal adding-on. The goal of this study was to study the postoperative progression of the lumbar curve in Lenke 1 scoliosis operated on with a LIV based on dynamic X-ray results. MATERIALS AND METHODS Right-sided Lenke 1 IAS that was treated surgically by posterior arthrodesis alone with a follow-up of at least 2 years was included in the study. The following radiographic parameters were evaluated: the Cobb angles of the curves, reducibility of the curves, the apex of the scoliosis, the central sacral vertical line, the stable vertebra (SV), the neutral vertebra (NV), the distances between the CSVL and the centroids of the LIV and of the first vertebra below instrumentation, as well as the tilt of the superior endplates. sROM and cROM were determined on dynamic X-rays. RESULTS Fifty IAS were evaluated/185 files. Only three cases fulfilled the criteria for AO including two that were secondary to peri- or postoperative complications. The lumbar curve presented with a loss of correction of 0.9° at one year and 1.14° at the final follow-up. None of the parameters studied were correlated to the deterioration of the lumbar curve. DISCUSSION The choice of the LIV has been shown to influence the deterioration of the lumbar curve and the development of AO. The choice of the LIV based on an analysis of AP (coronal) and lateral (sagittal) range of motion seems to prevent the development of AO. LEVEL OF EVIDENCE 4, retrospective study.

The concordance of MRI and arthroscopy in traumatic meniscal lesions in children

INTRODUCTION Traumatic meniscal lesions in children must be diagnosed quickly and efficiently as a priority in order to conserve the meniscus and safeguard the future of the knee. They are often isolated and difficult to identify clinically. In the diagnostic work up stage, an excessive resort to diagnostic arthroscopy has given way to increasing use of MRI by radiologists without pediatric specialization. The present study examined the agreement between MRI aspect and arthroscopic exploration in traumatic meniscal lesions in children. PATIENTS AND METHODS Sixty-nine knees in children aged 9 to 16 years having undergone MRI followed by arthroscopy for knee trauma between 1995 and 2008 were included in a retrospective design. Discoid meniscus was excluded. Files were reviewed by a single clinician and MRI scans by a radiologist specialized in pediatric pathology. Cases of epiphyseal fusion were excluded. All files were analyzable. Agreement with arthroscopic findings as reference was assessed for presence, location and type of meniscal lesion. RESULTS Overall agreement with arthroscopy was respectively 78% and 82% on first and second MRI readings: 77% and 80% for the medial, and 78% and 84% for the lateral meniscus. On the first reading, there were 13 false positives for the medial and 5 for the lateral meniscus, versus 9 and 0 respectively on second reading. Overall sensitivity was 70% on first reading and 64% on second, and overall specificity 81% and 90%, respectively. DISCUSSION The present results, in line with the literature, may appear encouraging, but hide considerable disparity between analysis of the medial and of the lateral meniscus: MRI overestimated medial and underestimated lateral meniscus lesions. CONCLUSION MRI serves only as a support and does not provide sure diagnosis of meniscus lesion. Interpretation should take account of the clinical examination and the pediatric orthopedic specialists experience.

Lumbosacral arthrodesis for neuromuscular scoliosis using a simplified Jackson technique

UNLABELLED Treating patients with severe neuromuscular scoliosis by long spinal fusion improves their quality of life and provides significant comfort for the patient and caregivers. But lumbosacral (L5-S1) fusion is challenging in these patients because of the significant deformities that result in poor bone anchoring quality and a risk of impingement between the skin and implants. In 1993, Jackson described a L5-S1 fusion technique using S1 pedicle screws and intrasacral rods (implanted under X-ray guidance) that are linked to the construct above with connectors. The goal of this study was to evaluate the clinical and radiological results and the postoperative complications of a simplified version of this technique, which does not require connectors or X-ray guidance. MATERIALS AND METHODS Thirty-three patients were evaluated with a minimum follow-up of 4years (average 82months). Frontal balance, sagittal balance, Cobb angle, sacral slope, lumbar lordosis and lateral pelvic tilt in the frontal plane were assessed on preoperative, postoperative and follow-up X-rays. Intraoperative and postoperative complications were recorded. RESULTS Complete fusion was obtained in 32 patients. The average Cobb angle was 62° initially and was reduced to 20° after surgery and 24° at the final follow-up. The average lateral pelvic tilt was 10.3° (0 to 26°) initially; it was surgically corrected to an average of 7.5° (0 to 24°); the average secondary loss of correction was 1.2° (0 to 9°). The sacral slope was corrected to an average of 11.2°; an average of 0.2° had been lost at the last follow-up (0 to 18°). Although the average for lumbar lordosis was unchanged, the standard deviation went from 29° to 16° after the corrective surgery and 17° at the last follow-up, with large cluster of measurements around the average value of 40°. The deformity correction was comparable to the results with other techniques (Galveston, sacroiliac screws); the complication rate was similar but the non-union rate was lower. This simplified Jackson technique appears to be an effective, simple method for L5-S1 fusion to correct neuromuscular scoliosis as it provides stable results over time. LEVEL OF EVIDENCE Level IV, retrospective study.

SFP PC-39 - Quelle maladie rechercher devant une pseudarthrose congénitale ?

Objectif La pseudarthrose congenitale est une anomalie rare accessible a un traitement. Elle est parfois secondaire a une pathologie specifique. Sujet Nous rapportons le cas d’un nouveau-ne a terme ayant une deformation du membre inferieur gauche. L’examen montre un sillon cutane supramalleolaire medial sans deviation sagittale. Les mobilites active et passive du genou et de la hanche sont normales. Les membres superieurs et le rachis sont indemnes. On constate des taches cafe au lait (TCL) sur le tronc ainsi que chez le pere et les deux grandes sœurs en faveur d’une Neurofibromatose de type 1 (NF1) familiale. Resultat La radiographie confirme une incurvation tibio-peroniere avec un aspect dystrophique de l’os, sans trait de fracture, en faveur d’une pseudarthrose congenitale. Conclusion La NF1 est la plus frequente des maladies rares. Les signes revelateurs habituels sont les TCL et un antecedent familial. La pseudarthrose est une complication rare mais connue de NF1 qui peut meme contribuer au diagnostic des la naissance.

P484 - Présentation inhabituelle d’une spondylodiscite à Kingella Kingae chez un enfant

Objectif Decrire une observation de spondylodiscite aigue avec signes cliniques inhabituels chez un enfant. Observation Un enfant de 3 ans a ete hospitalise pour des crises associant erection et douleurs abdominales survenant de facon pluriquotidienne le jour ou la nuit. L’enfant se plaignait depuis 4 semaines de douleurs lombaires d’installation progressive et accentuees lors de la marche. Il n’avait pas ete note de fievre. L’examen clinique montrait une diminution des mobilites du rachis lombaire et une hyperlordose a la marche. Au bilan sanguin, la VS et le fibrinogene etaient eleves alors que la CRP et la Procalcitonine etaient normales. Les hemocultures etaient steriles. L’IRM rachidienne revelait une spondylodiscite L3-L4 avec abces epidural posterieur fusant vers les foramens de L3. La ponction biopsie disco-vertebrale scano-guidee mettait en evidence un kingella kingae a la culture. L’evolution etait favorable apres antibiotherapie et immobilisation par un corset. Conclusion La spondylodiscite de l’enfant est un diagnostic rare et difficile. Elle doit etre suspectee devant toute douleur vertebrale de rythme inflammatoire, meme en absence de fievre et imposer la realisation d’une IRM rachidienne Dans notre cas, la physiopathologie de l’erection n’est pas clairement etablie.

SFCE-06 – Cancérologie, hématologie, immunologie – Etude rétrospective des cas pédiatriques français de maladie de Gorham (1988-2007)

La maladie de Gorham se presente comme une osteolyse au sein de laquelle se developpe un tissu vasculaire et lymphatique anormal, touchant de preference les enfants et les adultes jeunes. En 1955, L.W.Gorham en a defini les principales caracteristiques. Plus de 300 cas ont ete deja publies, mais les criteres diagnostics restent mal definis et la physiopathologie peu elucidee. Dans l’objectif de mieux la caracteriser, nous avons etudie retrospectivement les patients pris en charge pour une maladie de Gorham en France sur ces 20 dernieres annees. Nous en rapportons les differentes caracteristiques epidemiologiques,cliniques, histologiques et radiologiques. Methodes Les correspondants de la Societe Francaise des cancers de l’enfant ont ete contactes par mailing, ainsi que les auteurs de cas francais rapportes dans la litterature. Une fois un cas identifie, les differents medecins referents du patient ont ete recontactes et les dossiers des patients ont ete colliges sur chaque site. Resultat Nous avons identifie 17 cas en France. Aucun regroupement de cas familiaux n’est observe et la maladie apparait sporadique. La moyenne d’âge a la decouverte de la maladie est de 7 ans et demi [1–16 ans], avec un sex-ratio de 2,2. La decouverte de la maladie se fait le plus souvent a l’occasion d’une complication : fracture osseuse ou tableau de detresse respiratoire en rapport avec des lymphangiectasies ou un chylothorax. 63 % des cas presentent une atteinte osseuse multifocale et 81 % au moins une localisation extra osseuse. Les complications pulmonaires et rachidiennes conditionnent le pronostic, et la mortalite globale est de 25 %. Apres une duree de phase active de plusieurs annees [1–13 ans], les lesions ne semblent plus evoluer. Mais, les atteintes osseuses constituees pendant la phase active laissent de lourdes sequelles avec l’absence de reconstruction osseuse secondaire complete. Les bisphosphonates, l’interferon et la radiotherapie ont ete utilises pour enrailler cette phase active, et pour certains cas une reponse favorable a court terme a ete observee. Conclusion La maladie de Gorham est une maladie extremement rare, le plus souvent multiviscerale et tres severe. L’analyse des donnees retrospectives doit servir a proposer des recommandations pour sa prise en charge.