Manon Bachy

Infections after spinal correction and fusion for spinal deformities in childhood and adolescence

BackgroundInfection after spinal fusion for scoliosis is a commonly reported complication. Although techniques in paediatric spinal fusion have improved with regard to infection prophylaxis, postoperative infection rates range from 0.4% to 8.7%.Infection rates and causative factorsThe rate of infection in surgery for adolescent idiopathic scoliosis (AIS) has ranged from 0.9% to 3%. The rate of infection in spinal surgery for deformity related to myelomeningocele has been reported to be from 8% to 24%. The rate of infection in spinal surgery for deformity related to cerebral palsy has been reported to be from 6.1% to 8.7%. Infection after spinal fusion for scoliosis related to a muscular dystrophy is generally less frequent. Despite a large number of cases and studies, the literature did not provide documentation of several factors that may be related to the occurrence of wound infection. The rate of wound infection after spine surgery is dependent on many factors, including the complexity of the procedure, health status of the patient, and potentially the experience and technique of the operating surgeon.Treatment algorithmThe general algorithm for treatment depends on a variety of factors, including the delay from the index procedure, the infecting organism, the location and extent of the infection, the gross appearance of the fusion mass, and the surgical strategy used to correct the initial deformity. For infections that develop within the first 90 days after the index procedure all attempts to retain the instrumentation should be made. In late infections, the fusion mass must be carefully inspected before instrumentation removal is considered. Although fusion may appear to be solid both radiographically and intra-operatively, there still may be the possibility of loss of correction at last follow-up.ConclusionDeep wound infection after instrumented fusion of the spine remains a difficult and challenging clinical problem and entails substantial morbidity, cost, and recovery time for the patient. An aggressive approach to deep wound infection emphasising early irrigation and debridement allowed preservation of instrumentation and successful fusion in most cases. At the conclusion of treatment, patients can expect a medium-term clinical outcome similar to patients in whom infectious complication did not occur.

Efficacy of integuseal for surgical skin preparation in children and adolescents undergoing scoliosis correction.

Study Design. Prospective randomized trial. Objective. To explore the use of a microbial sealant applied before the surgical incision to reduce surgical site infection in patients with scoliosis. Summary of Background Data. The incidence of superficial or deep infections is reported in 2 groups of patients treated for neuromuscular or adolescent idiopathic scoliosis. Statistical analysis aimed to compare the effect of the use of a cyanoacrylate microbial sealant on infection rate. Methods. From June 2010 to June 2011, 56 patients were prospectively enrolled in the study. Using a random number table, patients were assigned either to receive or not a sterile, film-forming cyanoacrylate liquid application (Integuseal). Epidemiological data and infection occurrence were compared in both groups. Results. Statistical analysis comparing patients with neuromuscular scoliosis and adolescent idiopathic scoliosis showed that patients with neuromuscular scoliosis had more fused levels, increased intraoperative bleeding, and longer intraoperative time. Six patients had early postoperative infections of the posterior approach, which included 3 deep and 3 superficial infections. Five infections occurred in patients treated with Integuseal. Outcome was favorable in 6 cases after local wound debridement and antibiotics. Nonparametric statistical tests (Fisher exact test) showed no significant correlation (P = 0.096) between early postoperative infection occurrence and the use of Integuseal. Conclusion. Although microbial sealant may be a useful addition to a multimodal approach to minimize surgical site infection, there is currently insufficient evidence as to whether the use of microbial sealants reduces the risk of surgical site infection in patients undergoing scoliosis surgery.

Postoperative perceived health status in adolescent following idiopathic scoliosis surgical treatment: Results using the adapted French version of scoliosis research society outcomes Questionnaire (SRS-22)

PURPOSE Assessing functional outcome from patient-based outcomes questionnaires are essential to the evaluation of adolescent idiopathic scoliosis surgical treatment METHODS At the minimum follow-up of 2 years, 45 operated on adolescent idiopathic scoliosis patients were mailed the French version of the Scoliosis Research Society Outcome Instrument (SRS-22) questionnaires containing items on pain, activities of daily living, and satisfaction. RESULTS Mean values of the SRS-22 domains were 3,66 for the Pain domain, 3,85 for the Self-perceived image domain, 4,32 for the Function domain, 3,52 for the Mental health domain and 4,12 for the Global satisfaction with management domain. Mean value of the global SRS-22 score was 3,88. We showed no differences in functional SRS-22 health status in patients according to the type of curve (Lenke classification). We showed statistically significant correlations between the gain of Cobb angle and Patients self-image and function domain scores. There was a statistically significant correlation between preoperative Cobb angle and patient satisfaction with management. CONCLUSIONS Even if Function and Self-image scores in our patients are close to control group values, indicating good short to mid-term outcome of surgical treatment, scores for pain and mental health status were significantly lower in patients than controls. Long-term follow-up studies conducted by multiple surgeons over successive generations are mandatory to assess clinical significance of these differences. LEVEL OF EVIDENCE Level IV. Retrospective study.

Osteoid osteoma mimicking Brodie's abscess in a 13-year-old girl

Osteoid osteoma is a solitary, benign lesion of bone causing significant nocturnal pain. Magnetic resonance imaging (MRI), computed tomography (CT), and bone scan are commonly used in this diagnosis. A case of osteoid osteoma of the distal femur mimicking chronic osteomyelitis with Brodies abscess is reported and discussed. Initial radiographs and MRI showed a lesion of the distal femur consistent with subacute osteomyelitis with a Brodies abscess. Because primary malignant tumor could not be eliminated, surgical biopsy was carried out. Histological examination showed a typical nidus consistent with the diagnosis of osteoid osteoma. Subacute osteomyelitis (Brodies abscess) may be difficult to distinguish from other malignant or benign bone lesions as osteoid osteoma. CT usually is recommended as the best imaging procedure to identify the nidus and confirm the diagnosis. MRI also can be used for this purpose. Surgical biopsy remains mandatory for unclear lesions before deciding on appropriate treatment.

The Use of Magnetic Resonance Imaging in Management of Minimally Displaced or Nondisplaced Lateral Humeral Condyle Fractures in Children.

Objectives Fractures of the lateral humeral condyle are common in children. Nondisplaced fractures are managed with cast immobilization and frequent radiographic follow-up. Possibility of assessing the displacement and stability of such fractures may be helpful in planning the initial treatment and survey. Magnetic resonance imaging (MRI) could be a useful tool in determining the stability of lateral condyle in children. We propose to investigate the use of MRI in such indication. Methods Fourteen patients presenting with a minimally displaced or nondisplaced fracture were initially treated with a long arm cast and had an MRI within 5 days of injury. Results The MRI showed that 10 patients had an incomplete fracture without disruption of the cartilage hinge and 4 patients had a complete fracture with extension of the fracture through the cartilaginous epiphysis into the elbow joint. Three patients with such complete fracture had no evidence of lateral condyle displacement on MRI, and 1 patient had a displacement of the lateral condyle. The patients with incomplete fractures had a conservative treatment. The patient with a complete and displaced fracture had an open reduction and internal fixation. The 3 patients with a complete fracture and no evidence of lateral condyle displacement on MRI had a control MRI, 6 to 10 days after cast application, to detect a secondary displacement of the fracture. Conclusions Because it seems difficult in minimally displaced or nondisplaced fractures to detect further displacement with radiographs, MRI was found mandatory to improve complete fracture visualization during the first phase of conservative treatment. In incomplete fractures, initial MRI investigation was consistent with a stable fracture and avoided further early radiographs or clinical survey. In such cases, we recommend a conservative treatment with late radiographs after long arm cast removal. We propose MRI routine use in the early evaluation of minimally displaced or nondisplaced lateral condyle fractures in children.

All-Pedicle Screw Fixation With 6-mm-Diameter Cobalt-Chromium Rods Provides Optimized Sagittal Correction of Adolescent Idiopathic Scoliosis.

Purpose: Recently introduced cobalt-chromium (CoCr) rods that rely solely on pedicle screws produce very good results in correcting scoliotic curves. All-pedicle screws constructs are also suspected of decreasing thoracic kyphosis. The current study was designed to evaluate sagittal correction in adolescent idiopathic scoliosis patients, using 6-mm CoCr rods and all-screw constructs. Materials and Methods: A total of 61 patients treated by posterior spinal fusion and instrumentation, using all-pedicle screw constructs were included. The mean age at surgery was 15.4 years (range, 12–18 y). Forty-five patients (group A) were diagnosed with decreased thoracic kyphosis, and 16 patients (group B) had normal (35–50 degrees) thoracic kyphosis. Results: The preoperative main Cobb angle was 62.93±19.38 degrees in group A and 73.45±22.13 degrees in group B. In group A, the postoperative main Cobb angle was 23.33±12.71 degrees. In group B, the postoperative main Cobb angle was 27.20±10.04 degrees. The T4–T12 thoracic kyphosis improved postoperatively from 18.15±10.29 to 28.18±8.35 degrees in group A. In group B, the postoperative T4–T12 thoracic kyphosis was 40.34±3.13 degrees. Statistical analysis showed a significant improvement between preoperative and postoperative values of T4–T12 thoracic kyphosis in group A. In group B, the differences in T4–T12 thoracic kyphosis values were not statistically significant. Conclusions: Our result demonstrates a significant improvement of T4–T12 thoracic kyphosis in the hypokyphotic group of patients and confirms that CoCr rods can produce sagittal corrections in hypokyphotic adolescent idiopathic scoliosis patients. Our results confirm the benefit of combining all-pedicle screw constructs with a posterolateral translational in situ bending procedure to correct hypokyphosis directly.

Oral Ambulatory Treatment of Acute Osteomyelitis in Children: A Case-Control Study.

AbstractThe treatment of acute hematogenous osteomyelitis has evolved in recent years to a shorter parenteral treatment with an early switch to the oral route. Current publications recommend a 2- to 4-day parenteral treatment before the oral switch. We retrospectively analyzed a series of 45 children aged 1 to 11 years and treated in our department for acute osteomyelitis without severity criterion. Nineteen of 45 patients were treated by an exclusive ambulatory oral treatment by amoxicillin and clavulanic acid. Twenty six of 45 patients had a 2- to 4-day parenteral treatment before the oral switch. The minimum follow-up was 6 months. The primary endpoint was a clinical, radiographic, and biologic healing, 6 months after the beginning of the treatment. The secondary endpoints evaluated were the length of hospitalization, the total duration of treatment, and the type of antibiotic used. On the primary endpoint, we did not find any significant difference between the 2 treatments (P = 0.38). On the duration of treatment, we found a significant difference (P = 0.049) in favor of oral treatment. The ambulatory oral treatment by amoxicillin and clavulanic acid seems to be a valid alternative to the classical parenteral then oral sequence in the treatment of acute hematogenous osteomyelitis in children without severity criterion.

How can surgeonfish help pediatric surgeons? A pilot study investigating the antinociceptive effect of fish aquariums in adult volunteers

Animal-assisted therapies are associated with cognitive, physical and psychosocial benefits. They have also been used in the context of pain management, although there has been little research investigating the effect of such therapies on pain perception. In this study, a group of volunteers was asked to observe fish in a large aquarium, and pain perception during a painful stimulus was compared between this group and a control group not exposed to the aquarium.

Tendon lengthening and transfer.

Tendon lengthening and transfer are usually indicated for certain neuromuscular disorders, peripheral or central nerve injury, congenital disorder or direct traumatic or degenerative musculotendinous lesion. In musculotendinous lengthening, technique depends on muscle anatomy, degree of correction required, and the need to avoid excessive loss of force. Lengthening within the muscle or aponeurosis is stable. In the tendon, however, it may provide greater gain but is not stable and requires postoperative immobilization to avoid excessive lengthening. Tendon transfer consists in displacing a muscles tendon insertion in order to restore function. The muscle to be transferred is chosen according to strength, architecture and course, contraction timing, intended direction, synergy and the joint moment arm to be restored. Functions to be restored have to be prioritized, and alternatives to transfer should be identified. The principles of tendon transfer require preoperative assessment of the quality of the tissue through which the transfer is to pass and of the suppleness of the joints concerned. During the procedure, transfer tension should be optimized and the neurovascular bundle should be protected. The method of fixation, whether tendon-to-bone or tendon-to-tendon suture, should be planned according to local conditions and the surgeons experience.

A radiolucent chair for sitting-posture radiographs in non-ambulatory children: use in biplanar digital slot-scanning

EOS imaging (EOS System; EOS imaging, Paris, France) enables fast 2-D/3-D imaging of children in standing load-bearing position. Non-ambulatory children with neuromuscular scoliosis need evaluation of their spinal balance while in a normal daily position. We designed a customized chair fitting the EOS patient-area dimensions to obtain images in natural sitting postures. The chair is a 360° rotating orthopaedic chair made of fully radiolucent polyethylene and equipped with an adjustable headrest and three-point belts. Out of 41 consecutive patients, 36 (88%, 95% confidence interval 74–96%) had successful imaging. In most patients with severe neuromuscular trunk deformities, the EOS system combined with our chair was useful for assessing preoperative trunk collapse, pelvic obliquity and postoperative corrections in all planes. This specific device changed our daily practice for the assessment of spinal deformities in non-ambulatory patients.