Khalil Kharrat

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.

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.

Aneurysmal Bone Cyst of the Cervical Spine in Children: A Review and a Focus on Available Treatment Options.

Objective: To present a series of pediatric cervical spine (CS) aneurysmal bone cysts (ABC), to review the literature, and to propose a treatment algorithm. Material: We present a series of 4 cases of ABC and review the literature using PubMed, EMBASE, and Google scholar. Results: Only 51 cases are documented. The mean age at diagnosis is 11.5 years, and there is a small female predominance (F:M ratio=1.6). Most of ABC occurs in the upper CS (41%), are located in the posterior component (75%), and extends in 40% of the vertebral body. A single treatment modality was used in 56.9%, whereas combination of surgery with other treatment modalities was used in the rest. Of the total number of cases, 56.8% were managed with marginal resection, and instrumentation was used in 80%. Mean follow-up was 72.5 months, with the majority of patients disease free. Pain is the most common symptom present at the latest follow-up. Conclusions: ABC of the spine is a pediatric tumor occurring rarely in the CS. Treatment options vary from simple curettage to total resection with or without instrumentation. Recurrence after surgery is highest after curettage alone. The main indications for surgery are rapid progression, despite intracystic injection, and/or the presence of neurological signs or symptoms. Level of Evidence: Level IV.

Herniated intervertebral disc associated with a lumbar spine dislocation as a cause of Cauda Equina syndrome: a case report

To report a case of Cauda Equina syndrome with the completion of the paralysis after the reduction of a L4L5 dislocation due to a herniated disc. Although several articles have described a post-traumatic disc herniation in the cervical spinal canal, this is not well known in the lumbar region. A 30-year-old man was admitted to the emergency room with blunt trauma to the chest and abdomen with multiple contusions plus a dislocation of L4-L5 with an incomplete neurological injury. After an emergency open reduction and instrumentation of the dislocation, the patient developed a complete cauda equina syndrome that has resulted from an additional compression of the dural sac by a herniated disc. In a dislocation of the lumbar spine, MRI study is mandatory to check the state of the spinal canal prior to surgical reduction. A posterior approach is sufficient for reduction of the vertebral displacement, however an intra-canal exploration for bony or disc material should be systematically done.

Osteochondritis of the Distal Tibial Epiphysis

Osteochondritis of the distal tibial epiphysis is a very rare entity. 9 cases have been described in 7 articles and 8 other cases have been mentioned in textbooks. This paper describes the 10th case of osteochondritis of the distal tibial epiphysis and summarizes the clinical and radiological presentations of the 9 other cases. The etiology of this entity is well debated in the literature. We believe that it results from a vascular abnormality in the distal tibial epiphysis associated with a mechanical stress (trauma, excessive overload, etc.). Since it is a self-limited disease, the prognosis is good and the younger the patient is the better the prognosis will be. In general, this entity responds well to conservative treatment.

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.