P. Violas

Classification of chance fracture in children using magnetic resonance imaging.

Study Design. MRI study of pediatric Chance fracture. Objective. To evaluate bone and soft tissue lesions in pediatric Chance fracture. Summary of Background Data. Several descriptions and classifications have been already developed for Chance fracture, but mainly for adult. Furthermore, they are all based only on radiographic studies. Methods. MRI and radiographs of 18 children with Chance fracture were analyzed before treatment. Results. On MRI, in all cases, no abnormal signs were noted on the intervertebral disc. Six patients had a bone fracture going through the pedicle and the vertebral body. Twelve patients had a physeal injury located on the superior or on the inferior vertebral endplate. Three types of lesions could be identified according to the location of the lesion in relation to the pedicle. Conclusion. MRI is useful in the diagnosis of pediatric Chance fracture. It allows physeal injury to be clearly identified from disc injury.

Complications in pediatric spine surgery using the vertical expandable prosthetic titanium rib: the French experience.

Study Design. Multicenter retrospective study of 54 children. Objective. To describe the complication rate of the French vertical expandable prosthetic titanium rib (VEPTR) series involving patients treated between August 2005 and January 2012. Summary of Background Data. Congenital chest wall and spine deformities in children are complex entities. Most of the affected patients have severe scoliosis often associated with a thoracic deformity. Orthopedic treatment is generally ineffective, and surgical treatment is very challenging. These patients are good candidates for VEPTR expansion thoracoplasty. The aim of this study was to evaluate the potential complications of VEPTR surgery. Methods. Of the 58 case files, 54 were available for analysis. The series involved 33 girls and 21 boys with a mean age of 7 years (range, 20 mo–14 yr and 2 mo) at primary VEPTR surgery. During the follow-up period, several complications occurred. Results. Mean follow-up was 22.5 months (range, 6–64 mo). In total, 184 procedures were performed, including 56 VEPTR implantations, 98 expansions, and 30 nonscheduled procedures for different types of complications: mechanical complications (i.e., fracture, device migration), device-related and infectious complications, neurological disorders, spine statics disturbances. Altogether, there were 74 complications in 54 patients: a complication rate of 137% per patient and 40% per surgery. Comparison of the complications in this series with those reported in the literature led the authors to suggest solutions that should help decrease their incidence. Conclusion. The complication rate is consistent with that reported in the literature. Correct determination of the levels to be instrumented, preoperative improvement of nutritional status, and better evaluation of the preoperative and postoperative respiratory function are important factors in minimizing the potential complications of a technique that is used in weak patients with complex deformities. Level of Evidence: 4

Quantification of intervertebral disc volume properties below spine fusion, using magnetic resonance imaging, in adolescent idiopathic scoliosis surgery.

Study Design. Prospective clinical study. A quantification of volume and hydration variation of the intervertebral discs, using magnetic resonance imaging (MRI), in the lumbar spine before and after surgery performed in adolescent idiopathic scoliosis (AIS). Objectives. To evaluate an objective quantification of volume and hydration of intervertebral discs below spine fusion in scoliosis surgery. Summary and Background Data. Repercussion of long spine fusion on the free lower lumbar spine is one of the major concerns of scoliosis surgery. However, the evolution of lumbar intervertebral disc below thoracolumbar fusions remains unknown. Methods. MRI performed in the clinical protocol, concerned 28 patients having an idiopathic scoliosis. They underwent posterior instrumentations. MRI was obtained before surgery, after surgery at 3 months and for 15 patients at 1 year. MRI data were posttreated using a custom-made image processing software to semiautomatically derive volume properties of disc, anulus fibrosus, and nucleus pulposus. The nucleus-disc volume ratio was also an indicator of the hydration level. Results. The reliability of the three-dimensional reconstruction process was initially verified using an intraoperator reproducibility test. Original preoperative data on disc volume properties were then derived. Postoperative volume variations were quantified in discs below spine fusion taking into account the level of the arthrodesis and the disc location. It showed that the postoperative volume criteria increased significantly for nucleus, disc, and nucleus-disc volume ratio and some magnitude modulation could be conditioned by the location of surgical instrumentation. Some stabilization or reduction depending on disc level and arthrodesis size between 3 months and 1 year is observed in the follow-up. It tended to prove that the recovery of balance physiologic positioning and inherent biomechanical loads could induce a restored hydration of disc, which should favor the remodeling of free segments. Conclusions. This work was the first report dealing with consequences of scoliosis surgery on subjacent disc in term of volume and hydration properties.

Isolated meniscal injuries in paediatric patients: Outcomes after arthroscopic repair

BACKGROUND The management of isolated meniscal tears in paediatric patients is poorly standardised, and few published data are available. Nevertheless, there is widespread agreement that meniscectomy, even when partial, produces poor outcomes including the premature development of osteoarthritis. HYPOTHESIS Arthroscopic repair of isolated meniscal tears in paediatric patients yields good outcomes and should be attempted routinely. MATERIALS AND METHODS We retrospectively assessed 19 arthroscopic repair procedures performed between 2006 and 2010 by a single surgeon in 17 patients with a mean age of 14 years. In every case, the knee was stable and the meniscus normal before the meniscal tear, which was the only injury. Mean follow-up was 22 months. In all 19 cases, the evaluation included a physical examination, pre-operative magnetic resonance imaging (MRI), and determination of the Tegner and Lysholm scores. Post-operative MRI was performed in 10 cases. RESULTS The outcome was good in 12/17 (70%) patients with significant improvements in the mean Tegner score, from 3.9 to 7.1, and mean Lysholm score, from 55.9 to 85.4, between the pre-operative and post-operative assessments. The clinical outcomes were not significantly associated with time to arthroscopic repair, gender, lesion site, or lesion type. Neither was any correlation demonstrated between clinical outcomes and meniscal healing as assessed by MRI. DISCUSSION The known poor outcomes after meniscectomy in paediatric patients, the results of our study, and previously published data support routine arthroscopic repair of isolated meniscal tears in this age group, regardless of the site and type of injury. In addition, in asymptomatic patients, clinical follow-up is sufficient and post-operative MRI unnecessary. LEVEL OF EVIDENCE Level IV. Retrospective study.

Hereditary sensory and autonomic neuropathy type IV and orthopaedic complications

Hereditary sensory and autonomic neuropathy type IV (HSAN-IV) is a very rare autosomal recessive disorder characterized by recurrent episodes of unexplained fever, extensive anhidrosis, total insensitivity to pain, hypotonia, and mental retardation. The most frequent complications of this disease are corneal scarring, multiple fractures, joint deformities, osteomyelitis, and disabling self-mutilations. We reported the case of a 12-year-old boy. The goal was to discuss our decision-making and compare this case with cases described in the literature.

Percutaneous hallux valgus surgery in children: short-term outcomes of 33 cases.

BACKGROUND Many surgical procedures for hallux valgus correction have been reported, including percutaneous techniques. In children, the risk of recurrent hallux valgus after any type of surgical correction seems to deserve attention. To our knowledge, no studies have investigated the outcomes of percutaneous hallux valgus surgery in children. Here, we report a study on this topic. MATERIALS AND METHODS We retrospectively reviewed 33 percutaneous surgical procedures to correct idiopathic hallux valgus in 18 children younger than 16 years of age. Radiographs obtained pre-operatively and at last follow-up were used to determine the hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA). Clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and a satisfaction score. RESULTS Mean follow-up was 30 months. At surgery, mean age was 12.5 years and the growth plates were open in 20/33 (61%) cases. Mean HVA correction was 8.6° (from 28.06° to 19.45°, P<0.01) and mean DMAA correction was 7° (from 15.97° to 8.97°, P<0.01). At last follow-up, 20 (61%) feet had HVA values greater than 16°, but in half these cases the patients reported being satisfied with the procedure, leaving 30% of feet with symptomatic under-correction. Mean post-operative AOFAS score was 80.7. Patients were satisfied or very satisfied for 24/33 (73%) feet. DISCUSSION We found a high-rate of radiographic under-correction. Studies of factors associated with recurrent hallux valgus would be expected to result in technical improvements and therefore in better outcomes. CONCLUSION Our evaluation of short-term outcomes after percutaneous hallux valgus surgery without internal fixation showed both a high-rate of under-correction and a high-rate of patient satisfaction. Medium-term studies are needed to determine whether these results are sustained over time. The available data suggest a number of technical improvements. At present, we plan to continue to offer this procedure to children and their families. LEVEL OF EVIDENCE Level IV, retrospective study.

Idiopathic club foot treated with the Ponseti method. Clinical and sonographic evaluation of Achilles tendon tenotomy. A review of 221 club feet

The Ponseti method applied to treating idiopathic club foot consists in placing successive corrective casts, possibly an Achilles tendon tenotomy, then derotation braces, a method that has proven its efficacy. This study compared 221 cases of club foot treated with this method between 2002 and 2007 divided into two groups, based on whether or not Achilles tendon tenotomy was performed. Assessment was both clinical and sonographic. We observed clear improvement of the results in the group that underwent Achilles tendon tenotomy and a significant difference in the rate of secondary surgery. The sonographic evaluation also showed improvement of the morphological results. We now systematically propose Achilles tendon tenotomy however severe club foot may be.

Embolie graisseuse au cours des allongements de membres par clou centromédullaire : à propos de trois cas

Several methods are available for progressive limb lengthening, including centromedullary nailing, external fixation, or a combination. Each technique has its own advantages and drawbacks. In trauma victims, use of centromedullary nailing is associated with potentially fatal fat embolism. This fatal outcome might also occur during limb lengthening, particularly in bilateral procedures. To our knowledge, fat embolism has not been reported with the use of centromedullary nail for limb lengthening. This was a multicentric study of three cases of fat embolism, including one fatal outcome. In all, 36 centromedullary lengthening nails were inserted in the three centers before these acute episodes. The first two cases occurred during single-phase bilateral procedures, the third during unilateral lengthening. Fat embolism could result from several factors, as reported in the literature. While the bilateral nature of the procedure has been incriminated, the observation of an embolism during a unilateral procedure suggests other factors may be involved. Considerable increase in endomedullary pressure during reaming and insertion of the nail has been demonstrated. At the same time, there is the question as to whether the reduction of the diminution of medullary pressure by corticotomy would be an efficient way of reducing the risk of fat embolism. Based on the analysis of our three cases, we suggest that the best way to avoid fat embolism might be to drill several holes within the area of the osteotomy before reaming, in order to reduce endomedullary pressure. This can be achieved via a short skin incision, sparing the periosteum before low energy osteotomy. Since applying this protocol, the three centers have implanted 17 lengthening nails, without a single case of fat embolism.

Irreducible developmental dysplasia of the hip due to acetabular roof cartilage hypertrophy. Diagnostic sonography in 15 hips.

INTRODUCTION Irreducible developmental dysplasia of the hip (DDH) in newborns is a rare entity. The different obstacles preventing reduction have been described in the literature. HYPOTHESIS A clinical form of DDH with hypertrophy of the cartilage of the acetabular roof (acetabular bulge) can be reliably identified on ultrasound and should probably be defined as a separate entity. MATERIALS AND METHODS For the first time, the authors report their experience, a review of the literature and the radiographic description (ultrasound, arthrography MRI) of irreducible neonatal DDH due to hypertrophy of the cartilage of the acetabular roof (acetabular bulge) in 12 infants (15 hips). RESULTS Neonatal sonography seems to be sufficient to identify this specific clinical entity without any additional work-up. This sonographic sign could help determine the therapeutic strategy earlier in this severe and complex form of DDH.

Monopolar-probe monitoring during spinal surgery with expandable prosthetic ribs

BACKGROUND Intraoperative monitoring (IOM) has been proven to decrease the risk of neurological injury during scoliosis surgery. The vertical expandable prosthetic titanium rib (VEPTR) is a device that allows spinal growth. However, injuries to the spinal cord and brachial plexus have been reported after VEPTR implantation in 2 and 5% of patients, respectively. Simultaneous monitoring of these two structures requires the use of multiple time-consuming and complex methods that are ill-suited to the requirements of paediatric surgery, particularly when repeated VEPTR lengthening procedures are needed. We developed a monopolar stimulation method derived from Owens monitoring technique. This method is easy to implement, requires only widely available equipment, and allows concomitant monitoring of the spinal cord and brachial plexus. The primary objective of this study was to assess the reliability of our technique for brachial plexus monitoring by comparing the stability of neurogenic mixed evoked potentials (NMEPs) at the upper and lower limbs. HYPOTHESIS We hypothesised that the coefficients of variation (CVs) of NMEPs were the same at the upper and lower limbs. MATERIAL AND METHODS Twelve VEPTR procedures performed in 6 patients between 1st January 2012 and 1st September 2014 were monitored using a monopolar stimulating probe. NMEPs were recorded simultaneously at the upper and lower limbs, at intervals of 150 s. The recording sites were the elbow over the ulnar nerve and the popliteal fossa near the sciatic nerve. Wilcoxons test for paired data was used to compare CVs of the upper and lower limb NMEPs on the same side. RESULTS Mean CV of NMEP amplitude at the lower limbs was 16.34% on the right and 16.67% on the left; corresponding values for the upper limbs were 18.30 and 19.75%, respectively. Mean CVs of NMEP latencies at the lower limbs were 1.31% on the right and 1.19% on the left; corresponding values for the upper limbs were 1.96 and 1.73%. The risk of type I error for a significant difference between the upper and lower limbs was 0.5843 on the right and 0.7312 on the left for NMEP amplitudes and 0.7618 on the right and 0.4987 on the left for NMEP latencies. CONCLUSION Using an epidural active electrode and a sternal return electrode allows simultaneous stimulation of the cervical spinal cord and brachial plexus roots. The NMEPs thus obtained are as stable (reliable) at the upper limbs as at the lower limbs. This easy-to-implement method allows simultaneous monitoring of the upper and lower limbs. It seems well suited to VEPTR procedures. LEVEL OF EVIDENCE IV, retrospective single-centre non-randomised study.