Yann Philippe Charles

Accuracy of the Sauvegrain Method in Determining Skeletal Age During Puberty

BACKGROUNDnThe method of Sauvegrain et al. for the assessment of skeletal age from radiographs of the elbow is useful during the two years of the pubertal growth spurt. The purpose of this study was to determine the accuracy of the method and its value in pediatric orthopaedics.nnnMETHODSnThe Sauvegrain method uses four anatomical landmarks of the elbow: the lateral condyle, trochlea, olecranon apophysis, and proximal radial epiphysis. It is based on a 27-point scoring system. The scores for these structures are summed, and a total score is determined. A graph is then used to determine the skeletal age. The method was evaluated by three independent observers who used it to assess skeletal age on anteroposterior and lateral radiographs of the left elbow of sixty boys and sixty girls and compared the results with assessments made with use of the Greulich and Pyle atlas on posteroanterior radiographs of the left hand and wrist. Skeletal age determinations were performed twice by each observer at a four-week interval.nnnRESULTSnThe skeletal age determination from radiographs of the elbow was more precise because a clear semiannual age determination was possible. On the basis of the rating by the observers, the Sauvegrain method presented excellent interobserver correlation (r = 0.93) and excellent reproducibility (r = 0.96). The correlation between the methods of Sauvegrain et al. and Greulich and Pyle was good (r = 0.85). Nevertheless, certain elbow growth centers showed an intermediate developmental morphology, which failed to correspond to the score described by Sauvegrain et al. This led to errors in the interpretation of data. We suggest an intermediate score for these cases, and we modified the original graph to make it more accurate.nnnCONCLUSIONSnThe modified method of Sauvegrain et al. is simple, reliable, and reproducible, and it complements the Greulich and Pyle atlas. In clinical practice, maturity can best be evaluated by associating skeletal age, annual growth rate, and secondary sexual characteristics. Therefore, this method is useful when major decisions such as the timing of epiphysiodesis or spinal arthrodesis are necessary during puberty.

Comparative Clinical Outcomes of Submuscular and Subcutaneous Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome

PURPOSEnTo determine retrospectively whether the technique of ulnar nerve transposition (subcutaneous versus submuscular) is associated with clinical sensory and motor recovery in cubital tunnel syndrome, and whether recovery is influenced by prognostic factors such as preoperative McGowan stage, age, and duration of symptoms.nnnMETHODSnTwenty-five patients (average age, 53 years; follow-up, 7 years) with cubital tunnel syndrome had submuscular transposition, and 24 patients (average age, 46 years; follow-up, 3 years) were treated by subcutaneous transposition. There were 11 McGowan stage II and 14 stage III patients in the submuscular group and 14 stage II and 10 stage III patients in the subcutaneous group. Preoperatively, all patients presented with diminished 2-point discrimination. Postoperative sensory and motor recovery was evaluated clinically.nnnRESULTSnThere was no significant difference between subjective results in the submuscular and subcutaneous groups: 20 of 25 patients in the submuscular group versus 17 of 24 patients in the subcutaneous group were clearly improved, and 3 of 25 patients in the submuscular group versus 6 of 24 patients in the subcutaneous group partially improved. The logistic multivariate regression analysis indicated that sensory and motor function were both significantly improved following both surgical techniques. Sensory function recovered (2-point discrimination <6 mm) in 17 of 25 patients in the submuscular group and in 17 of 24 patients in the subcutaneous group, and motor function recovered (intrinsic strength grade 5) in 19 of 25 patients in the submuscular group and in 19 of 24 patients in the subcutaneous group. Symptoms lasting more than 6 months were associated with a poor prognosis.nnnCONCLUSIONSnSensory and motor recovery for patients with McGowan stages II and III of cubital tunnel syndrome were similar following submuscular and subcutaneous transposition techniques, and patients with symptoms lasting longer than 6 months had a worse prognosis regardless of surgical technique.

Skeletal age assessment from the olecranon for idiopathic scoliosis at Risser grade 0.

BACKGROUNDnThe main progression of idiopathic scoliosis occurs during peak height growth velocity, which is between the ages of eleven and thirteen years in girls and thirteen and fifteen years in boys and corresponds to the accelerating phase of pubertal growth. The Risser sign remains at grade 0 during this stage of growth. Triradiate cartilage closure occurs at approximately twelve years of age in girls and fourteen years in boys, which is in the middle of this phase. In addition to regular height measurements, a more detailed evaluation of skeletal maturity would be desirable prior to the identification of Risser grade 1. From the method of Sauvegrain et al., Diméglio derived a simplified method based on the radiographic appearance of the olecranon, which allows skeletal age to be assessed in six-month intervals. The purpose of this study was to determine the accuracy and the value of this simple method for the follow-up of patients with scoliosis.nnnMETHODSnFive radiographic images demonstrate the typical characteristics of the olecranon during pubertal growth: two ossification nuclei, a half-moon image, a rectangular shape, the beginning of fusion, and complete fusion. This classification method was evaluated by three experienced and independent observers from lateral radiographs of the elbow in 100 boys and 100 girls with idiopathic scoliosis during the time of peak height velocity. Skeletal ages were correlated with the integral Sauvegrain method. The degree of interobserver concordance was determined, and skeletal age was compared with chronological age and the time of triradiate cartilage closure.nnnRESULTSnFor the three observers, the average concordance between the Sauvegrain and olecranon methods was excellent (r = 0.977 for boys and r = 0.938 for girls). The interobserver agreement was also excellent (r = 0.987 for the olecranon method and r = 0.958 for the Sauvegrain method for boys, and r = 0.992 and r = 0.985, respectively, for girls). Skeletal and chronological age were considered to correspond to each other within a six-month range for 49% of the boys and 51% of the girls, while 25% of the boys and 26% of the girls had an advanced skeletal age and 26% of boys and 23% of girls had a delayed skeletal age. Triradiate cartilage closure occurred at the same time as the appearance of the rectangular shape of the olecranon in 65% of the boys and 61% of the girls, corresponding to skeletal ages of fourteen and twelve years, respectively. In 91% of the boys and 88% of the girls, the triradiate cartilage fused within six months before to six months after the appearance of the rectangular shape of the olecranon, which occurred between the half-moon image and the beginning of fusion of the olecranon.nnnCONCLUSIONSnThe method of assessing skeletal age from the olecranon allows skeletal maturity to be evaluated in regular six-month intervals during the phase of peak height velocity. This method is simple, precise, and reliable. It complements the Risser grade-0 and the triradiate cartilage evaluation.

Influence of idiopathic scoliosis on three-dimensional thoracic growth.

Study Design. Prospective clinical study of three-dimensional thoracic growth in children with idiopathic scoliosis and a reference group. Objective. To measure thoracic dimensions and volume in relation to growth and to verify the influence of scoliosis. Summary of Background Data. Scoliosis represents a three-dimensional spinal deformity leading to thoracic deformity. Vertical expandable prosthetic titanium rib distraction primarily treats this deformity, but little is known about thoracic growth in scoliosis. Methods. One hundred and thirty children with scoliosis (20 boys, 110 girls; 4–16 years; curves 15°–45°; rib hump 5–25 mm) were compared with 126 children without spinal deformity (61 boys, 65 girls). The ORTEN system was used for optical trunk surface data acquisition. Thoracic volume, perimeter, anterior-posterior and transversal diameters, T1–T12 and sternal lengths were calculated and related to age, weight, standing and sitting height. Results. There was no significant difference in thoracic volume between the 2 groups (P > 0.05). The correlation between thoracic volume (3–16 dm3) and growth parameters was greater (R2 > 0.70) than with age. At 4 years, thoracic volume represents 33%, and at 10 years, it represents 55% of its volume at 16 years. It triples between 4 and 16 years and doubles during puberty. These relationships were constant in all groups. During growth, the transversal diameter corresponds to 30%, the anterior-posterior diameter represents 20% and the thoracic perimeter 100% of sitting height. Conclusion. The thoracic deformity in scoliosis is measurable with ORTEN, but scoliosis ≤45° with a rib hump ≤25 mm does not significantly influence thoracic volume. Thoracic parameters should be related to sitting height rather than age. Established relationships give a reliable indication of thoracic proportions, which are useful for understanding global spinal and thoracic deformity and for optimizing braces or surgical strategies. Further investigations are required for curves >45°, leading to major thoracic asymmetry.

Skeletal age assessment from elbow radiographs. Review of the literature

Skeletal age is important to evaluate remaining growth. In 50% of normal children and adolescents, skeletal age does not differ from chronological age. During puberty, skeletal age is an important tool when performing a lower limb epiphysiodesis or when treating (conservatively or surgically) patients with spinal deformities. Skeletal age alone is not enough and should be assessed together with other clinical and radiological findings such as standing and sitting heights, Risser sign, Tanner stages and annual growth rate. Puberty starts at 11 years of skeletal age and ends at 13 years of skeletal age in girls; in boys, puberty starts two years later (13 years of skeletal age) and then ends at a skeletal age of 15. Most current clinical and radiographic markers do not help paediatric orthopaedic surgeons to clearly distinguish maturity levels prior to Risser I. Sauvegrain et al. developed a method to assess skeletal age by using elbow radiographs (AP and lateral projections). Between 11 and 13 years of skeletal age in girls and between 13 and 15 years of skeletal age in boys, the olecranon apophysis is characterised by a clear morphological development. This method is a reliable tool to assess skeletal age during puberty because significant morphological changes in the elbow happen every six months.

Skeletal age determination from the elbow during pubertal growth

The Sauvegrain et al. method of assessing skeletal age from elbow radiographs is useful during the 2 years of the pubertal growth spurt: between 11 and 13 years in girls and between 13 and 15 years in boys. This method uses four ossification centers of the elbow: lateral condyle, trochlea, olecranon apophysis, and proximal radial epiphysis. It is based on a 27-point scoring system. The scores of these structures are summed, a total score is determined, and a graph is then used to determine the skeletal age. This simple, reliable, and reproducible method complements the Greulich and Pyle atlas, which does not allow assessment of skeletal age in 6-month intervals during the phase of accelerating growth velocity. In clinical practice, maturity can best be evaluated by associating skeletal age, annual growth rate, and Tanner stages. Skeletal age assessment from the elbow is useful to plan the timing of epiphysiodesis in limb length inequality or to evaluate the progression risk of idiopathic scoliosis.ZusammenfassungDie Methode zur Skelettaltersbestimmung an Röntgenbildern des Ellbogens nach Sauvegrain et al. ist während der beiden Jahre des pubertären Wachstumsschubes nützlich: zwischen 11 und 13xa0Jahren bei Mädchen und zwischen 13 und 15xa0Jahren bei Jungen. Sie basiert auf einem Score von 27xa0Punkten und berücksichtigt die Reifestadien folgender 4 Epiphysenkerne des Ellbogens: Condylus lateralis humeri, Trochlea humeri, Olecranon und Radiusköpfchen; deren jeweilige Punkte werden addiert und der Score somit bestimmt. Anhand einer Graphik lässt sich das Skelettalter mit dem ermittelten Score ablesen.Diese Methode ist einfach anzuwenden und zeichnet sich durch eine hohe Reliabilität und Wiederholbarkeit aus. Sie ergänzt den Atlas nach Greulich u. Pyle, der eine Skelettalterbestimmung in 6-monatigen Altersstufen während des akzelerierten pubertären Wachstums nicht erlaubt. In der Klinik lässt sich die Wachstumsreife am besten durch Kombination des Skelettalters, der jährlichen Wachstumsrate und der Tanner-Stadien beurteilen. Die Skelettaltersbestimmung am Ellbogen ist wichtig, um den Zeitpunkt der Epiphyseodese im Rahmen von Beinlängendifferenzen zu planen oder um das Progredienzrisiko idiopathischer Skoliosen einzuschätzen.AbstractThe Sauvegrain et al. method of assessing skeletal age from elbow radiographs is useful during the 2xa0years of the pubertal growth spurt: between 11 and 13xa0years in girls and between 13 and 15xa0years in boys. This method uses four ossification centers of the elbow: lateral condyle, trochlea, olecranon apophysis, and proximal radial epiphysis. It is based on a 27-point scoring system. The scores of these structures are summed, a total score is determined, and a graph is then used to determine the skeletal age.This simple, reliable, and reproducible method complements the Greulich and Pyle atlas, which does not allow assessment of skeletal age in 6-month intervals during the phase of accelerating growth velocity. In clinical practice, maturity can best be evaluated by associating skeletal age, annual growth rate, and Tanner stages. Skeletal age assessment from the elbow is useful to plan the timing of epiphysiodesis in limb length inequality or to evaluate the progression risk of idiopathic scoliosis.

Skelettaltersbestimmung am Ellbogen während des pubertären Wachstums

The Sauvegrain et al. method of assessing skeletal age from elbow radiographs is useful during the 2 years of the pubertal growth spurt: between 11 and 13 years in girls and between 13 and 15 years in boys. This method uses four ossification centers of the elbow: lateral condyle, trochlea, olecranon apophysis, and proximal radial epiphysis. It is based on a 27-point scoring system. The scores of these structures are summed, a total score is determined, and a graph is then used to determine the skeletal age. This simple, reliable, and reproducible method complements the Greulich and Pyle atlas, which does not allow assessment of skeletal age in 6-month intervals during the phase of accelerating growth velocity. In clinical practice, maturity can best be evaluated by associating skeletal age, annual growth rate, and Tanner stages. Skeletal age assessment from the elbow is useful to plan the timing of epiphysiodesis in limb length inequality or to evaluate the progression risk of idiopathic scoliosis.ZusammenfassungDie Methode zur Skelettaltersbestimmung an Röntgenbildern des Ellbogens nach Sauvegrain et al. ist während der beiden Jahre des pubertären Wachstumsschubes nützlich: zwischen 11 und 13xa0Jahren bei Mädchen und zwischen 13 und 15xa0Jahren bei Jungen. Sie basiert auf einem Score von 27xa0Punkten und berücksichtigt die Reifestadien folgender 4 Epiphysenkerne des Ellbogens: Condylus lateralis humeri, Trochlea humeri, Olecranon und Radiusköpfchen; deren jeweilige Punkte werden addiert und der Score somit bestimmt. Anhand einer Graphik lässt sich das Skelettalter mit dem ermittelten Score ablesen.Diese Methode ist einfach anzuwenden und zeichnet sich durch eine hohe Reliabilität und Wiederholbarkeit aus. Sie ergänzt den Atlas nach Greulich u. Pyle, der eine Skelettalterbestimmung in 6-monatigen Altersstufen während des akzelerierten pubertären Wachstums nicht erlaubt. In der Klinik lässt sich die Wachstumsreife am besten durch Kombination des Skelettalters, der jährlichen Wachstumsrate und der Tanner-Stadien beurteilen. Die Skelettaltersbestimmung am Ellbogen ist wichtig, um den Zeitpunkt der Epiphyseodese im Rahmen von Beinlängendifferenzen zu planen oder um das Progredienzrisiko idiopathischer Skoliosen einzuschätzen.AbstractThe Sauvegrain et al. method of assessing skeletal age from elbow radiographs is useful during the 2xa0years of the pubertal growth spurt: between 11 and 13xa0years in girls and between 13 and 15xa0years in boys. This method uses four ossification centers of the elbow: lateral condyle, trochlea, olecranon apophysis, and proximal radial epiphysis. It is based on a 27-point scoring system. The scores of these structures are summed, a total score is determined, and a graph is then used to determine the skeletal age.This simple, reliable, and reproducible method complements the Greulich and Pyle atlas, which does not allow assessment of skeletal age in 6-month intervals during the phase of accelerating growth velocity. In clinical practice, maturity can best be evaluated by associating skeletal age, annual growth rate, and Tanner stages. Skeletal age assessment from the elbow is useful to plan the timing of epiphysiodesis in limb length inequality or to evaluate the progression risk of idiopathic scoliosis.

Curve progression risk in a mixed series of braced and nonbraced patients with idiopathic scoliosis related to skeletal maturity assessment on the olecranon.

We aimed to determine the curve progression risk of idiopathic scoliosis in patients at the time of peak height velocity by plotting curve magnitudes against olecranon stages of skeletal maturation. Register data of 372 patients with juvenile or adolescent idiopathic scoliosis followed at 6-month intervals from onset of scoliosis to skeletal maturity were reviewed. At the onset of the pubertal growth spurt, curves greater than 30° have a 100% risk of progressing over 45° (P<0.0001). Curves 21–30° have a progression risk of 72.5% (P=0.0034). A curve progression velocity 6–10° per year represents a risk of 71.8% (P=0.0001) to require surgical treatment and a velocity greater than 10° per year represents a risk of 100% (P<0.0001). Plotting curve magnitudes against height measurements and the stages of olecranon maturation offers a reliable prediction of curve progression risk in idiopathic scoliosis during Risser 0.

Safety and efficacy of sublaminar bands and Ponte osteotomies in rigid deformity: preliminary results in a prospective series of 20 neuromuscular scoliosis patients

This prospective cohort study investigated radiographic outcomes and complications over time in patients with rigid neuromuscular scoliosis treated with sublaminar bands and Ponte osteotomies. Twenty consecutive patients with neuromuscular scoliosis were treated with sublaminar bands in addition to Ponte osteotomies at and around the apex of the deformity and prospectively included. All curves were rigid, with less than 30% reduction on preoperative bending films. Cobb angle, pelvic obliquity, and shoulder obliquity were significantly corrected (P<0.01). Normal thoracic kyphosis was achieved for 85% of patients at the last follow-up. No intraoperative complications were observed. The association between Ponte osteotomies and sublaminar bands appears to be efficient for the management of rigid neuromuscular deformities in children and adolescents. No death and no permanent neurological impairment, as well as no sublaminar bands associated events were recorded.

Risk of infection and secondary displacement in pediatric supracondylar or lateral condyle fractures treated with unburied Kirchener-wires removed before complete bone healing

This study evaluated the risk of infection and of secondary displacement among children with displaced lateral condyle or supracondylar fractures treated by surgery. The study included a consecutive sample of 84 supracondylar fractures and 21 lateral condyle fractures treated with closed reduction and percutaneous pinning. The mean time to Kirchener wire removal was 29 days (range: 25–37 days) postsurgery. Two out of 105 (1.9%) patients developed infectious complications and two of 105 (1.9%) patients had a secondary displacement. Removal of unburied Kirchener wires before complete bone healing in the physician’s office does not increase risk of infection or the risk of secondary displacement. The protocol does, however, enable significant savings and eliminates the need for additional anaesthetic.