R. Kohler

Pediatric bone and joint infections caused by Panton-Valentine leukocidin-positive Staphylococcus aureus.

Background: Panton-Valentine leukocidin (PVL) is a necrotizing toxin secreted by Staphylococcus aureus. PVL-positive S. aureus osteomyelitis and arthritis have been described. Methods: We analyzed demographic, clinical, laboratory, microbiologic, and imaging data in a study group of 14 pediatric cases with PVL-positive S. aureus osteomyelitis and arthritis diagnosed between 2001 and 2005 and compared results with a control group of 17 pediatric cases of PVL-negative S. aureus osteomyelitis and arthritis treated in our institution during the same period. Treatments and outcome were studied. Results: The severity of PVL-positive S. aureus bone and joint infections was indicated by the presence of severe sepsis in all cases and of septic shock in 6 of the 14 patients. By comparison, severe sepsis was not noted in the control group (P = 0.004). On admission, the median C-reactive protein value was significantly higher in the study group (202.6 mg/L versus 83 mg/L in the control group; P = 0.001). Eleven patients with PVL-positive infection had local extension of the infection by magnetic resonance imaging and 7 patients had severe deep-seated infectious complications by computed tomography. By contrast only 1 patient in the control group presented with bone abscess without extension and none had deep-seated infection (P < 0.001). The median length of hospitalization was 45.5 days in the study group versus 13 days in the control group (P < 0.001). The median duration of intravenous antibacterial chemotherapy was 48 days versus 11.3 days in the control group (P < 0.001). Ten patients (71%) of the study group required surgical procedures with a mean of 3 procedures (range, 1–5) whereas 3 patients (17%) of the control group required 1 surgical drainage each (P = 0.002). All the patients survived, but only 2 patients of the study group were free of long-term complications, whereas there were no long-term complications noted in the control group. Conclusion: PVL-positive S. aureus bone and joint infection is severe and requires prolonged treatment. Local complications are more frequent and often need repeated surgical drainage.

Induced membrane technique for reconstruction after bone tumor resection in children: a preliminary study.

AIM Segmental long-bone defect due to tumor resection remains a challenge to treat. The induced membrane technique is a new alternative for biological reconstruction. During the first stage, a cement spacer is inserted after bone resection and stabilisation. The cement spacer is removed during a second stage procedure performed after chemotherapy, and cortico-cancellous bone autograft was placed in the biological induced chamber. The aim of this study was to assess preliminary results in eight children. PATIENTS AND METHODS This prospective study included six girls and two boys, with a mean age of 12.1 years (range 9.5 to 18) and treated for a mean 15 cm defect (range 10 to 22 cms) due to resection of osteosarcoma (n=4), Ewing sarcoma (n=3) and low grade sarcoma. All patients except one, were given pre- and postoperative chemotherapy. Surgery was performed for three patients with a distal femur tumor, two patients with a proximal tibial tumor and three patients who had proximal humerus, shaft of humerus and fibular tumors. Fixation was mainly performed with locking compression plate (n=4) and locked nail (n=2). The mean operating times for first and second step procedures were 4.8 and 4h respectively. The healing process was radiologically assessed. RESULTS After a mean follow-up of 21.6 months (15 to 30), all patients were free of disease and seven had bony union. For the lower limb reconstructions, full weight bearing was possible after a mean of 116 days (range 90 to 150) following the second stage. Mean time to bone union was 4.8 months (1.5 to 10). The early Musculoskeletal Tumor Society (MSTS) score was 25.2/30 (range 20-30). Complications were: non-union (n=1), paradoxical graft resorption (n=1) requiring graft revision. CONCLUSION This two stage procedure reduces the operating time during the first stage and it also reduces early complications. Rapid bone union is objectively obtained despite major bone resection and the patients receiving chemotherapy. SIGNIFICANCE The induced membrane technique could be an excellent alternative for biological reconstruction after tumor resection in children.

Orthoses for mild scoliosis: a prospective study comparing traditional plaster mold manufacturing with fast, noncontact, 3-dimensional acquisition.

Study Design. A prospective comparison of 2 different methods to make orthoses in mild scoliosis. Objective. To evaluate the therapeutic efficiency of orthoses made by a computer-aided design procedure. Summary of Background Data. It is now possible to make orthoses by a computer-aided design procedure. In order to evaluate this new method, we carried out a comparative study between the traditional and computer-aided design-manufactured orthoses. Methods. In this prospective study, we compared the 2 methods by studying the cases of 30 adolescents with mild scoliosis. For each patient requiring orthopaedic treatment, we made 2 ortheses: 1 using the traditional method and 1 using the computer-aided design method. There were 26 girls and 4 boys whose average age was 13 years and 3 months. Each body jacket was successively used in random order following the same protocol. Neither the prescriber nor the patient knew the origin of the orthosis used. The final choice of the orthosis was made using 3 criteria: first, improvement of the scoliotic curves on the frontal and lateral radiologic planes, and second, the patient’s impression of comfort. Results. For the 30 cases, 13 traditional and 16 computer-aided design body jackets were chosen. In 1 case, no significant difference allowed us to chose one body jacket rather than the other. For the frontal radiologic correction, the better results were obtained 3 times with the computer-aided design body jacket, 5 times with the traditional one, and in 22 cases, the results were equivalent. For the lateral radiologic correction, the better results were obtained 11 times with the computer-aided design body jacket, 3 times with the traditional one, and in 16 cases, the results were equivalent. For the comfortof the 2 body jackets for each patient, the better results were obtained 12 times with the computer-aided design body jacket, 8 times with the traditional one, and in 10 cases, the results were equivalent. Conclusion. Based on our results, we believe that the computer-aided design procedure is equally efficient to traditional method for mild scoliotic curves.

Osteoid osteoma transformation into osteoblastoma: fact or fiction?

BACKGROUND Osteoid osteoma and osteoblastoma are rare, benign, bone-forming tumours. The clinical presentation, imaging study findings, and course indicate clearly that these two tumours are distinct entities. CLINICAL REPORTS We report two cases suggesting transformation of osteoid osteoma into osteoblastoma and therefore inviting a discussion of the links between these two tumours. An 11-year-old girl with a small metaphyseal lesion of the proximal tibia was given a diagnosis of osteoid osteoma. Over the next few weeks, worsening pain and marked tumour growth prompted a biopsy, which was consistent with an aggressive osteoblastoma. A review of the case suggested primary osteoblastoma at the earliest stage of development. In a 14-year-old boy, en-bloc excision was performed to remove a 1cm defect located within the femoral shaft cortex and typical for osteoid osteoma. An asymptomatic recurrence measuring 20mm along the long axis was removed 18 months later. Reassessment of the histological slides indicated recurrence of an incompletely excised osteoid osteoma. DISCUSSION The histological similarities between osteoid osteoma and osteoblastoma, together with the lesion size criterion, may result in confusion. Collaboration between the clinician and pathologist is crucial and should take the tempo of evolution into account. CONCLUSION The histopathological differences between these two tumour types deserve to be emphasized. The data reported here challenge the concept that osteoid osteoma can transform into osteoblastoma. These two tumours are distinct entities that should no longer be differentiated based on size, as was long done in the past.

Aneurysmal bone cysts of the pelvis in children: a multicenter study and literature review.

The authors analyzed a series of 15 pelvic aneurysmal bone cysts (9 boys and 6 girls) in children and adolescents who were reviewed with an average follow-up of 50.3 months. Pain and limp were the main symptoms. Four patients had no treatment after the open biopsy. Eleven patients were treated with curettage. Preoperative selective arterial embolization was performed in three cases before curettage. Two recurrences were noted after curettage; recurrences were treated successfully with further curettage. As a result, the authors recommend curettage; more aggressive operative intervention does not appear to be indicated. No major intraoperative vascular complications occurred. Spontaneous healing in a few cases (even in active or aggressive lesions) argues for clinical and radiologic observation after biopsy when possible. In case of a propitious evolution, observation must be continued and surgery might be avoided, but if the lesion increases, treatment must be proposed.

Dépistage de la luxation congénitale de hanche chez le nourrisson: Un examen clinique systématique rigoureux. Un recours sélectif à l’échographie

Abstract (1) Clinical examination of the hips should be systematically performed in the newborn, in order to detect a possible congenital dislocation. This translates into hip joint instability, which can be evidenced by both Ortolani’s and Barlow’s signs, the latter being more sensitive. Special attention should be paid for abduction range, as limited abduction is a warning sign. (2) Use of imaging, especially sonography will be restricted to specific cases only. It’s prescription, technical realization as well as interpretation have to be carefully done, so that it is actually relevant to uncertain or “at risk” situations. (3) Treatment if needed, should be ideally managed by a paediatric orthopaedic surgeon.

Pseudarthrose congénitale de l’avant-bras associée à la neurofibromatose: À propos d’un cas et revue de la littérature

We report a case of congenital pseudarthrosis of the forearm associated with neurofibromatosis type 1 which was treated by free vascularized periosteal flap transplant and repeated bone grafting. The young female patient recovered good hand and forearm function. A review of the literature revealed the rare occurrence of this disease (approximately 100 cases reported to date), which probably explains the wide variety of surgical proposals.Resume Les auteurs rapportent un cas de pseudarthrose congenitale de l’avant-bras, associee a la neurofibromatose de type 1, qui a ete traite par un lambeau libre de perioste et des greffes osseuses a repetition. La jeune patiente a aujourd’hui une bonne fonction de la main et de l’avant-bras. Une revue de la litterature montre la rarete de cette affection (environ 100 cas rapportes a ce jour) expliquant la diversite des attitudes therapeutiques.

Cartable et pathologie rachidienne : Légende ou réalité ?

Resume Les rachialgies de l’adulte sont tres frequentes et celles de l’enfant aussi. Les facteurs de risque pour les rachialgies sont le sexe feminin, un mauvais etat de sante, des antecedents familiaux de rachialgies, un profil psychologique particulier, le temps passe a rester assis ou a regarder la television, le poids du cartable, la duree de port du cartable, des antecedents de traumatisme rachidien, une activite physique intense, la pratique de sports en competition et l’âge (plus frequent chez l’adolescent que chez l’enfant). Pour la plupart des auteurs, il existe une relation entre l’apparition de rachialgies et le port d’un cartable representant plus de 20 % du poids du corps. Beaucoup d’etudes fixent comme seuil conseille 10 % du poids du corps pour le cartable. Il semble que non seulement le poids du cartable mais la duree du port de celui-ci dans la journee soit un facteur favorisant pour l’apparition de rachialgies. Le mauvais positionnement du cartable peut modifier la posture et la marche. Le port du cartable sur les deux epaules entraine moins de modification de la posture et de la marche que le port du cartable sur une seule epaule. Il n’y a pas d’etude actuelle qui permette d’etablir une relation entre poids du cartable et developpement d’une deformation rachidienne structuralisee.

Traitement orthopédique de la scoliose: nouvelie technique de prise d'empreinte par procédé optique

The authors present a new procedure for acquiring the whole external trunk shape. The construction of braces starts with corrected a positive mold using computer-assisted design software connected to a digital tooling machine. The computer-assisted design and construction of braces enable the determination, measurement, and modification of a three-dimensional image of the trunk, which allows the positive to be corrected. The outer-trunk can be re-balanced, derotated or rectified in the sagittal or frontal plane and the inner modeling of the spine and chest can be rectified. Moreover, in the case of scoliosis or kyphosis, the software produces automatic correction. This rapid (acquisition time < 2 seconds), non invasive, safe and painless procedure can also be used to detect and follow mild spinal deformities.

Intérêt de la toxine botulique pour les suites opératoires en chirurgie des membres chez l'enfant infirme moteur cérébral

Resume La spasticite et les spasmes musculaires peuvent etre a l’origine de douleurs chez l’enfant infirme moteur cerebral (IMC). La realisation d’actes chirurgicaux orthopediques est souvent necessaire chez ces patients et les phenomenes douloureux postoperatoires peuvent etre aggraves par la spasticite, alors qu’elle est elle-meme augmentee par l’epine irritative que representent les douleurs postchirurgicales. De meme, ces symptomes peuvent etre aggraves par les mouvements anormaux, l’immobilisation plâtree ou encore l’anxiete des patients. Le traitement de la spasticite est une necessite apres une chirurgie orthopedique chez les enfants IMC. Une etude randomisee a montre recemment l’interet de l’utilisation de la toxine botulique (toxine botulique) avant une chirurgie tendineuse chez l’IMC. Le but de cette etude etait d’evaluer les benefices en termes de confort et de douleur, obtenus par l’utilisation de la toxine botulique dans le cadre d’une chirurgie osseuse realisee chez des enfants IMC tetraplegiques spastiques. Deux groupes de 9 patients IMC tetraplegiques spastiques ayant subi une intervention chirurgicale orthopedique pour chirurgie osseuse ou chirurgie multi-site ont ete compares lors d’une etude retrospective : un des groupes recevait de la toxine botulique avant l’intervention. Tous les patients ont ete immobilises en postoperatoire pour une duree moyenne de 6 semaines. Les principaux criteres etudies ont ete : l’efficacite et les effets secondaires de la toxine botulique, la duree de l’hospitalisation, de la douleur et du traitement antalgique de niveau III (morphine), la qualite du sommeil, enfin la survenue de lesions cutanees lors de l’immobilisation. Aucune difference significative ne separait les deux groupes de patients (en dehors du traitement par toxine botulique). L’efficacite et l’innocuite clinique de la toxine botulique ont pu etre confirmees. Aucune difference significative n’a ete retrouvee concernant la duree d’hospitalisation : 7,33 jours (e.t ± 1,5) contre 7,88 jours (e.t ± 1,7) ainsi que pour le duree d’utilisation d’antalgiques de niveau III : 4,33 jours (e.t ± 1,9) pour 4,16 jours (e.t ± 2,5). Cependant la duree des symptomes douloureux a diminue significativement de 6,87 jours (e.t ± 2,9) a 2,22 jours (e.t ± 1,7) et la qualite du sommeil des patients a ete significativement amelioree et les lesions cutanees sous immobilisation ont pu etre prevenues pour le second groupe. Ce travail ne permet pas de confirmer que l’utilisation de toxine botulique diminue la consommation d’antalgiques chez ces patients. Cependant nos resultats sont en faveur d’une diminution de la duree des phenomenes douloureux postoperatoires et d’une amelioration du confort des enfants IMC spastiques operes lorsqu’une administration de toxine botulique a ete realisee en preoperatoire. Cette etude suggere qu’un benefice peut etre attendu de l’administration de toxine botulique en preoperatoire et les auteurs conseillent d’etendre ses indications a toute chirurgie orthopedique realisee chez un patient spastique.