Fernand Dagher

Pediatric cervical spine instability

Cervical spine instability in children is rare but not exceptional and may be due to many factors. Although it mostly occurs at the upper cervical spine, all vertebrae from the occiput to T1 may be involved. It may be acute or chronic, occurring secondary to trauma or due to congenital anomaly, skeletal or metabolic dystrophy or rheumatoid arthritis. It can be isolated or associated with other musculoskeletal or visceral anomalies. A thorough knowledge of embryology, anatomy, physiology and physiopathology of the cervical spine in children is essential to avoid pitfalls, recognize normal variants and identify children at risk of developing cervical spine instability and undertake the appropriate treatment.

Radiofrequency application to the growth plate in the rabbit: a new potential approach to epiphysiodesis.

Background Radiofrequency energy is being used more and more frequently in orthopaedics, mainly in the treatment of bone tumors. We postulated that radiofrequency ablation may produce growth plate lesions similar to those observed in the bone and conducted this study to see whether radiofrequency may be used as a technique for producing epiphysiodesis. Methods We randomized 60 8-week-old female New Zealand white rabbits into 3 groups. Group A was destined for a total epiphysiodesis at 60°C, group B was destined for a total epiphysiodesis at 90°C, and group C for a lateral hemiepiphysiodesis at 90°C. Radiofrequency energy was delivered in 1 minute in all 3 groups. Using fluoroscopic imaging, radiofrequency was applied percutaneously to the left proximal tibial physis whereas the right growth plate received a sham procedure. A bicortical pin was used to evaluate the longitudinal growth rate at every monthly radiologic control, beginning 8 weeks after the procedure. Comparisons between the right and left side and between groups A and B were achieved using a paired t test. A histopathologic study was conducted in parallel to the radiographic study. Results In a radiograph at the 8-week point, pin migration was 4.74 mm on the left side compared with 9.72 mm on the right (P<0.0001), in group A. In group B, pin migration on the left was 1.37 mm compared with 5.49 mm on the right (P<0.0001). In group C, mean angular deviation was 11.6 degrees on the left compared with 1.9 degrees on the right (P=0.0001). These differences were maintained until the end of growth. Pathology specimens revealed cellular anarchy, loss of columnar stratification, and height of the physis on the left side, which occurred earlier and were more pronounced in group B than in group A. In group C, these changes involved only the lateral half of the left physis whereas its medial counterpart remained normal. There was no evidence of articular cartilage damage. Conclusions This experimental study shows that radiofrequency can efficiently and rapidly achieve epiphysiodesis. It is one of many methods that can be used for this purpose. The development of new electrodes suitable for use on human growth plates and the elaboration of specific utilization protocols may lead to its use in children. Its simplicity and precision may lead to a quick and efficient growth arrest with little pain and postoperative disability in addition to reduced costs. Clinical Relevance Radiofrequency has proved to be effective in producing growth arrest in rabbits with no complications. Technical improvements and adaptations may allow its use for pediatric limb inequalities or angular deformities in the near future.

Thermocoagulation percutanée scannoguidée de l’ostéome ostéoïde

Resume Le but de cette etude etait d’evaluer l’efficacite de la thermocoagulation percutanee de l’osteome osteoide, toutes tranches d’âge et toutes localisations confondues. Trente trois patients, âges de 7 a 39 ans, traites par thermocoagulation sous controle tomodensitometrique ont ete revus retrospectivement. Tous les patients ayant une lesion du membre inferieur ont ete capables de prendre un appui total en postoperatoire immediat, et de reprendre leur activite normale en 24 a 48 heures. La douleur a disparu immediatement apres thermocoagulation chez 26 patients et la boiterie, lorsqu’elle etait presente, a pris en moyenne 24 jours pour disparaitre. Au recul moyen de 34 mois, un seul patient avait une douleur et une boiterie persistantes. La guerison clinique a ete confirmee par tomodensitometrie et scintigraphie osseuse chez 12 patients. Cette methode precise et peu invasive s’est averee efficace, sure, et associee a une diminution des depenses de sante. Elle peut etre recommandee comme le traitement de choix de l’osteome osteoide.

A newly recognized autosomal recessive syndrome with short stature and oculo‐skeletal involvement

This report describes a young girl and her cousin presenting with postnatal short stature, strabismus, photophobia, retinitis pigmentosa, short neck, rhizomelic shortening of the long bones, short and slightly bowed humeri with prominent deltoid tuberosities, short and wide ribs and clavicles, dorso‐lumbar scoliosis, biconcave vertebral bodies of the thoraco‐lumbar spine, and narrowed lumbar canal. In addition, in the girl there were amelogenesis imperfecta of the hypomaturation type, and the radiographs showed short distal ulnae, sloping epiphyses of the radii, short femoral necks, and slightly flat uncovered femoral heads. The childrens parents are first cousins. Differential diagnoses are discussed and the possibility of a newly recognized oculo‐skeletal syndrome is raised.

Osteomyelitis of the rib due to Streptococcus pneumoniae: a very rare condition in children.

Rib osteomyelitis is a rare disease. We present a previously unreported case of Streptococcus pneumoniae osteomyelitis of the rib. A 4-month-old-infant presented with fever, irritability and abdominal tenderness. Pericostal collection was discovered incidentally on ultrasound; it was first drained by needle aspiration and appropriate antibiotic therapy was given, with resolution of fever in 24 h, but recurrence of symptoms 4 days later, with swelling over the affected rib. Surgical drainage with resection of the infected portion of the rib were done followed by a prolonged course of intravenous and then oral antibiotics, without any recurrence at 6 months follow-up. A review of the pertinent literature was made. This case demonstrates that the spectrum of pathogens potentially responsible for rib osteomyelitis may be broader than previously reported. The management and outcome are similar to rib osteomyelitis due to any other bacteria.

Rôle de la radiothérapie dans l’ossification hétérotopique

PURPOSE To evaluate the use of radiation therapy for the prevention of heterotopic ossification. PATIENTS AND METHODS Twenty-two patients, 20 to 76 years old were irradiated for the prevention of heterotopic ossification. All patients received a postoperative irradiation consisting of 700 cGy delivered by 18 MV photons using a linear accelerator. The delay between surgery and irradiation was 24 hours for 20 patients, 48 hours for three patients, 72 hours for two patients and 96 hours for one patient. The follow-up of all patients was based on radiologic findings (Brooker score) as well as the clinical status of the articulation before and after surgery. Of the 14 cases for which follow-up data was available, seven received primary prophylaxis and seven received secondary prophylaxis. RESULTS Heterotopic ossification prophylaxis using radiation therapy was radiologically successful in 71.5% of patients: 85.7% success for patients receiving primary prophylaxis and 57.1% success for patients receiving secondary prophylaxis. No functional failure was reported. No patient developed radiation related side effects. CONCLUSION Radiation therapy is proven to be effective in preventing heterotopic ossification. A larger study group is needed in order to compare our results with those seen in the literature.

Bursite bicipitoradiale de l’adolescent : une entité rare pouvant simuler une tumeur maligne

Bicipitoradial bursitis is a rare condition: we found 36 cases reported in the literature, none in children. The main manifestation is a painful tumefaction. We report a case observed in an adolescent whose magnetic resonance imaging findings were compatible with a malignant tumor. Surgical biopsy enabled the correct diagnosis of inflammatory synovium without signs of malignancy compatible with bicipitoradial bursitis. Complete cure was achieved without resection.

Dysplasia epiphysealis hemimelica of the elbow.

Dysplasia epiphysealis hemimelica (DEH) or Trevors disease is a rare disorder affecting the epiphyses and short bones of the limbs, and characterized by a benign overgrowth of the medial-half of the epiphysis resembling osteochondroma. Upper limb involvement is very rare and most commonly affects the carpal bones. Only five established cases of DEH around the elbow were found in the orthopedic literature. We herein report an additional case of Trevors disease of the elbow in a child with a symptomatic ulnar nerve compression and its management. To the best of our knowledge, this is the first case of DEH of the elbow presenting with nerve compromise.

Fibrodysplasie ossifiante progressive : écueils orthopédiques et controverses

Fibrodysplasia ossificans progressiva (FOP) is a rare disorder of the connective tissue associating malformation of the great toes and progressive heterotopic ossifications. Diagnosis is mostly clinical and currently no treatment is available. We report on the case of an 8 year old boy having an unusual form of FOP. We discuss clinical aspects of the disease and insist on the importance of early diagnosis, avoiding harmful events and therapeutic pitfalls.

Free vascularized fibular flap for congenital ulnar pseudarthrosis: a report of two cases and review of the literature.

Congenital pseudarthrosis of the ulna (CPU) is an extremely rare disorder that has been treated with various traditional methods with poor results on long-term deformity correction and bony union. Free vascularized fibular grafting (FVFG) has been used to treat congenital pseudarthroses with improved success rates. We report herein 2 cases of CPU treated with FVFG in which bone union was obtained without major difficulty. The distal ulnar hypoplastic physis and epiphysis were spared during excision of the pseudarthrosis in both cases leading to continuous ulnar growth following bone healing. The main challenge concerned the stability of the radiocapitellar joint. There was no complication at the donor site. Free vascularized fibula is a safe and effective method for the treatment of congenital pseudarthrosis of the ulna.