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To study the results and complications of Traditional Growing Rods (TGR) for the treatment of Early-Onset Scoliosis (EOS) in patients with Ehlers-Danlos syndrome (EDS).This is a retrospective study of patients with EDS treated for EOS between 2012 and 2018 by TGR. For each patient, we evaluated the evolution of the Cobb angle of the main coronal curve before the first surgery, postoperatively and at the last follow-up. We also noted every complication.Four patients have been evaluated. Age at the index surgery ranged from 3- to 6-year-old. All the patients had a Kyphoscoliosis. The preoperative Cobb angle of the main coronal curve ranged from 70° to 104°. Prior to surgery, a progressive correction of the spinal deformity by Halo-gravity traction was performed for all patients. One patient had several complications with a poor result after final fusion. Three patients did not sustain any complication and presented good results. Follow-up ranged from 3 to 8 years. For two of our patients, further lengthening procedures are still needed.TGR is a good surgical option for the treatment of EOS in EDS. A progressive preoperative correction is recommended. Anchor-related complications must be minimized in these patients with an important kyphosis. Level of evidence Level IV.

Mucopolysaccharidosis (MPS) is a multisystemic storage disorder of glycosaminoglycan deposits. Infiltration of the dura mater and supporting ligaments caused spinal cord compression and consecutive myelopathy, especially at the cranio-cervical junction (CCJ). Craniocervical instability and posterior decompression often raise the problem of fixation in children. The main purpose of this paper was to report the result of an original technique of occipito-cervical arthrodesis using a cranial halo-cast system in pediatric population.We recorded 21 patients with cervical myelopathy. All of them had spinal cord decompression by enlargement of the foramen magnum, C1 laminectomy, and occipito-C2 fusion using corticocancellous bone graft. Only one child has an extended laminectomy from C1 to C3. The occiput-C2 arthrodesis was stabilized by the cranial halo-cast system. This immobilization was performed preoperatively and kept for three months then switched to rigid cervical collar. Clinical assessment, including the Goel grade and mJOA, radiographs and magnetic resonance imaging were performed before surgery. The occipito-cervical arthrodesis was controlled by standard X-rays and CT scan.According to the type of mucopolysaccharidosis, the patients were divided into MPS type I: n= 3, II: n=7, IV: n=11. The mean age of patients at surgery was 6.76 years. All mucopolysaccharidoses cases required a foramen magnum decompression by craniectomy, C1 laminectomy and occipito-C2 arthrodesis. As major complications, a child had immediate post-operative paraplegia due to spinal cord ischemia. The postoperative follow-up ranged from 1.5 to 4 years, with an average of 3.3 years. The average preoperative mJOA score was 8.9, and it improved to 14 points at the last follow-up.Satisfactory fusion and good clinical results were obtained with the 2-stage approach to CCJ anomalies.

The evaluation of the internship in pediatric orthopedics is based on a clinical examination in the form of ECOS, after the internship period involving all surgical specialties. The validation of the clinical examination test does not necessarily mean that the student has achieved his internship objectives and vice versa. This discrepancy between the evaluation test and the field of the internship prompted us to question the need to establish a formative evaluation method during the clinical internship.Our study is a prospective, evaluative, longitudinal study, from October 2019 until September 2020, in the infantile orthopedics and traumatology department of the "Béchir HAMZA" children's hospital in Tunis. We carried out a formative evaluation using the "Patient Management Problem" (PMP), with two different subjects, one on acute hematogenous osteomyelitis, the other on malignant bone tumors, with a Pre-test and a Post-test for each PMP.We had 18 interns, during the period between October 2019 and September 2020, including 13 who had medical training in Tunisian faculties. The score for the acute osteomyelitis pretest was 14.56 on average, the PMP score was 16.33 on average, with one interne scoring zero. The posttest mean was 18.11 [13.75-20], with a statistically significant difference from the pretest. The pre-test for the bone tumors' PMP had an average of 9.7 [3.75-15], that of PMP was 12.6 [0-20]. There was an improvement in post test scores with an average of 16.45. Comparing the two tests we noticed that the scores for the PMP osteomyelitis were higher than the scores for the PMP bone tumors with a significant difference between the two groups (p = 0.04).The results of this pilot project are encouraging for the establishment of a continuous evaluation by the PMP method, intended for interne during the pediatric orthopedic surgery internship. This method allows learning and formative evaluation of learners by evaluating clinical and therapeutic reasoning.

Introduction and importance Navicular bone location of primary subacute hematogenous osteomyelitis uncommon. There are few cases reported in literature. We aim to describe the clinico-radiological features of primary subacute hematogenous osteomyelitis of the navicular bone in a 7-year-old child, to explain our management of this rare disease and demonstrate that medical treatment without surgery is enough. Case presentation A 7-year-old child presented to emergency department. His chief complaint was fever, left limping and foot pain. The positive examination features of were painful palpation of the dorsal side of the foot and a swelling of the homolateral ankle. The erythrocyte sedimentation rate was high. The x-ray revealed a lytic lesion of the left navicular bone. The MRI findings led to the diagnosis of subacute osteomyelitis. Pain relief and normalization of inflammatory markers were obtained after 8 weeks of antibiotic therapy. Complete radiological healing was obtained after 9 months. One year after treatment, the patient was able to practice sports as previously. Clinical discussion Subacute osteomyelitis of the navicular bone in pediatric population is a rare condition. This case shows the importance of early diagnosis thanks to MRI findings and appropriate antibiotic therapy based on the endemic bacteriological profile. Conclusion The navicular bone may develop primary subacute osteomyelitis in immunocompetent child. Early diagnosis is important for prescribing effective conservative treatment., Highlights • Subacute osteomyelitis of the navicular bone is an etiology of lameness in children. • The penumbra sign on MRI is strongly suggestive of the infectious origin of the bone involvement. • Medical treatment without surgery can lead to a cure. • Antibiotic therapy should be sufficiently prolonged for at least 3 months.

Introduction Septic osteomyelitis is a hematogenous bacterial bone infection. The acute presentation is the most common; the subacute one is less frequent. The aim of our case report is to put forward the features of this uncommon presentation and to propose a therapeutic management. Presentation of case We report a rare case of subacute osteomyelitis associated with Brodie's abscess of the tibial diaphysis in a four-year-old child. The chief complaint was a pain in the left tibia evolving for five weeks. The radiological findings and the unusual location of this pathology suggested a malignant bone tumor. Thanks to imaging assessment and bone biopsy the diagnosis of subacute osteomyelitis associated with Brodie's abscess was made. Therefore, the child had antibiotic therapy and plaster immobilization to avoid pathological fracture. Pain relief and radiological improvement was obtained after 3 months of antibiotic treatment. At a two-year follow-up, the X-ray was normal. Discussion We report an uncommon case of subacute osteomyelitis which evolved to Brodie's abscess with diaphyseal location. The mainstream treatment is surgery combined with antibiotics. However, medical treatment alone can lead to recovery without sequelae. Conclusion Because of the atypical location and presentation of subacute osteomyelitis, the other differential diagnoses, especially malignant bone tumors have to be eliminated. In some cases, treatment may be based on antibiotics therapy alone., Highlights • The MRI findings can mimic a malignant bone tumor. • The importance of the biopsy for the diagnosis. • Antibiotic treatment without surgery is an alternative for the treatment of circumscribed Brodie’s abscess.

Purpose The aim of this case report is to show that late diagnosis of vertebral osteoid osteoma gives rise to structural scoliosis which sometimes requires long-term management. Methods We report a case of an osteoid osteoma in the thoracic spine associated with structural scoliosis. We describe a 14-year-old boy who complained chronic nightly left back pain and scoliosis. Spine’s X-ray was reported thoraco-lumber scoliosis without bone lesion. Results MRI as well as technetium-99 m total body bone scan and a computed tomography scan revealed a bony lesion in the upper left joint of T11 vertebra consistent with the diagnosis of OO. Anatomopathological study of the resection piece confirmed the diagnosis of OO. Surgical excision of the tumor resolved pains, but scoliosis needed an orthopedic treatment for 1 year. Conclusion Through this case, it has been demonstrated that late diagnosed vertebral OO can be the cause of structural scoliosis. Clinical and radiological results indicate that OO resection is an effective and safe method of treatment. Levels of evidence IV.

Highlights • The treatment of bone defect is fraught with difficulties especially in septic conditions. • Consideration of the quality of bed tissue and the size of the bone defect are condition to ensure a good result. • Illizarov fixator is an attractive technique for solving discrepancy of the upper limb., Introduction The management of large bone defect in the upper limb is fraught with difficulties and problems. It’s is a long course treatment which include many components: infection, osseous loosening and shortening. Case presentation We present our experience of an 12-years-old boy with septic non union of the proximal left humerus with length discrepancy of 6 cm treated with Ilizarov fixator(IL) followed by vascularized fibula graft (VFG) with a good clinical result without complications. Discussion The bone loss may be treated with allografts, bone transfer and bone substitute. Consideration of the quality of bed tissue and the size of the bone defect are condition to ensure a good result. Conclusion Ilizarov fixator is an attractive and the most used technique for solving the problem of discrepancy and stabilizing in the upper limb.

Flatfoot is a frequent reason for consultation in pediatric orthopedics. The calcaneal lengthening osteotomy according to the EVANS technique is a therapeutic alternative. The objective of this work was to evaluate the short and medium term clinical and radiological results of calcaneal lengthening osteotomy in children with idiopathic flat foot valgus.This study concerned 12 children and 15 ft treated surgically by calcaneal lengthening osteotomy by an orthopedic surgeon in a pediatric orthopedic surgery center. The evaluation of the results was clinical according AOFAS score and radiological.The deformity was reducible in all of our patients. The mean preoperative AOFAS score was 61, postoperatively 90. The overall result was excellent in 11 cases (11 ft) and good in 4 cases. The postoperative radiological result was close to normal values.Calcaneal lengthening osteotomy is a reliable and recommended technique for the correction of symptomatic idiopathic flatfoot.IV, Case series.

Tuberculosis is a topical issue in endemic countries. Foot involvement is rare and accounts for 5-10% of all osteoarticular tuberculosis. Pediatric cases of osteoarticular tuberculosis are uncommon especially in well vaccinated children. The clinical presentation is not specific and can be confused with common germ like staphylococcus. Biopsy is mandatory in endemic zone, and if the evolution is not good with antibiotherapy. Debridement can be indicated but must be gentle, because of the risk of navicular necrosis.

Introduction and importance Most of the time, intramuscular hydatid cysts are secondary. The unusual topographies are a source of diagnostic delay and treatment difficulties. The aim of our case report is to put forward the features of this uncommon presentation and to propose a therapeutic management. Case presentation We report the case of a primary hydatid cyst located in the right lumbar paraspinal muscles in a ten-year-old girl, in good health and without a pathological medical history. The patient presented with a discreet right lumbar swelling of firm consistency, painless and without signs of inflammation. Ultrasound and magnetic resonance imaging suggested the diagnosis of an intramuscular paravertebral hydatid cyst. The hydatid serology was positive. The patient had en-bloc resection of the cyst. He was infected with pus. The histopathological examination confirmed the diagnosis of muscular hydatidosis. Medical treatment was started. Three years after the operation, the MRI confirmed that was no recurrence. Clinical discussion Echinococcus is a parasitic cestode that can infect dogs and other pets and farm animals, with humans as incidental hosts. Muscular hydatid localization, secondary to hematogenous dissemination, is rare, even in endemic countries. The combination of medical treatment with surgery ensures the best condition to avoid recurrence. Conclusion In regions where hydatidosis is endemic, a tumor in any part of the body should be considered a hydatid cyst until proven otherwise., Highlights • In endemic areas, any swelling should suggest hydatid cyst. • A negative hydatid serology does not rule out the diagnosis of hydatid cyst. • The hydatid cyst infection can occur through the hematogenous route. • MRI is efficient for the diagnosis of infected hydatid cyst. • The infection can sterilize the hydatid muscle cyst.

Obstetric brachial plexus palsy aredue to elongation of the brachial plexus during delivery by increasing thedistance between the head and shoulder. The majority of paralysis recoverspontaneously, but in some cases, nerve repair is necessary. The timing of thisnerve surgery and criteria for its indication are topics of discussion in theworld literature.The aim of this study is to askdirections and to evaluate the contribution of nerve surgery in improving theprognosis of this disease.This is a retrospective study thathas interested 68 cases of obstetric brachial plexus palsy who needs a nerverepair, collected over a 8 year-period (2004 - 2011). We analyzed the musclequotes and evaluate the functions of the shoulder, elbow and hand pre and postoperative. A minimum 12 months'follow-up was observed.Seventy-eight patients werecollected, 33 boys and 35 girls with a 62 days mean age at first consultationand a mean birth weight of 4187 grams . The presentation was cephalic in 66 cases. Theright side was interested in 66%. Clinically, we reported 50% of total brachialplexus palsy and 50% of C5-C6 palsy.The mean age at time of surgery was 9 months 10 days. Preoperatively, the shoulder was listed 0 or 1 according to Gilbert classification in 70% of cases in the C5-C6 plasy and 90% of the total brachial palsy. After a mean follow up of 30 months, the rate was respectively 9% and 15%. In 75% of cases of total brachial palsy, the hand was listed 0 according to Raimondi scale, while in postoperative, 65% of cases, the hand was listed 2 and 3 according to Raimondi scale. Nerve rupture was the predominant lesion on the C5 and C6 root while fibrosis was predominant on C7, C8 and T1 roots. We noted 6 complications including respiratory distress.The nerve repair should not beperformed too early or too late. Too soon, we may operate those who can have aspontaneous recovery. Too late, the installation of the degeneration of motorendplates and muscle atrophy render unnecessary nerve repair. The absence ofbiceps clinical recovery in the 6th month of life and the presence of root-wrenching signs represented the absolute surgical indications. Its results areencouraging and improve functional outcome.

We describe a case of osteomyelitis, in a 7-month-old boy, caused by S. pneumoniae involving the pelvic bone with a purulent collection in the adductor muscle. Osteomyelitis diagnosis was suspected using ultrasound and CT scan investigations. This showed a periosteal elevation in the Case Study Ben Marzouk et al.; IJMPCR, 3(3): 68-72, 2015; Article no.IJMPCR.2015.038 69 pelvis and an abscess of the adductor muscle. Culture of the perioperative specimens isolated serotype 19A S. pneumoniae with reduced susceptibility to penicillin and macrolides. The patient was treated successfully with amoxicillin-clavulanate during five weeks, associated with gentamicin during the first week.

La syndactylie congenitale de la main est l’une des malformations congenitales les plus frequentes. Sous ce terme sont regroupees des anomalies de severite tres variable. Plusieurs techniques chirurgicales ont ete proposees avec multiples dessins de lambeau. Le resultat final reste mitige. L’objectif de notre travail etait d’evaluer les resultats de la chirurgie des syndactylies dans notre service et de comparer les differentes techniques chirurgicales utilisees. Etude retrospective descriptive monocentrique des syndactylies congenitales de la main operees au service d’orthopedie pediatrique a l’hopital Bechir Hamza entre 2011 et 2015. Nous avons utilise deux types de lambeaux commissuraux dorsaux : le premier type omega est un lambeau avec greffe cutanee et le deuxieme V-Y en ilot de Sherif est un lambeau d’avancement metacarpien sans greffe cutanee. Sur les 38 patients etudies, la syndactylie etait plus frequente chez les garcons (sex-ratio = 1,71). D’autres malformations associees etaient trouvees chez 20 patients (53 %). Quatorze patients (37 %) avaient des syndactylies bilaterales. Sur les 65 commissures operees, 41 (63 %) etaient simples, 15 (23 %) etaient complexes et 9 (14 %) etaient compliquees. La troisieme commissure etait la commissure la plus atteinte (52 %). L’intervention etait pratiquee en moyenne a l’âge de 30 mois. Cinquante et une commissures etaient operees par un lambeau omega et quatorze par un lambeau V-Y en ilot de Sherif. Les suites operatoires etaient simples pour toutes les syndactylies sauf 2 cas d’infection. Nous avons trouve 19 commissures compliquees (29 %) et 10 recidives (15 %) toutes reoperees. Nous avons recueilli 39 bons resultats (60 %), 19 resultats moyens (29 %) et 7 mauvais resultats (11 %). La satisfaction moyenne des parents etait de 7,4 sur 10. Il n’y avait pas de difference entre les deux types de lambeau utilises en termes de complications, recidives, reprises et resultat final. Le taux de recours a la greffe cutanee etait significativement plus eleve avec le lambeau omega qu’avec le lambeau de Sherif (p = 0,001). Ni le recours a la greffe cutanee ni le type de lambeau utilise n’etaient des facteurs predictifs de mauvais resultats. Seulement le type de syndactylie a influence le type de resultat. Le traitement de la syndactylie est toujours un traitement chirurgical. Le resultat final depend surtout du type de la syndactylie. Pour les syndactylies simples, il est recommande de limiter les greffes cutanees qui sont plus predictives de complications.

Summary Introduction Deep venous thrombosis (DVT) is rare in children. It may complicate acute hematogenous osteomyelitis (AHO). Objective The present study assessed the incidence of DVT in community-acquired AHO, and compared clinical and laboratory characteristics with AHO without DVT. Patients and methods A prospective study included patients treated for community-acquired AHO between April 2007 and December 2009. Results Seventy patients were included: mean age, 7.7 years. Seven developed DVT. All involved Staphylococcus aureus. The isolated Staphylococcus aureus was significantly more often methicillin-resistant than methicillin-susceptible (p = 0.04). C-reactive protein, erythrocyte sedimentation rate, positive blood culture and incidence of pulmonary staphylococcus were significantly higher in patients with DVT. These patients also had significantly more febrile days. One patient with DVT died from severe refractory respiratory failure. Discussion DVT was observed in 10% of cases of community-acquired AHO. DVT was associated with more severe onset, with extensive local disease. Surgery was often needed to drain a subperiosteal abscess. DVT can cause invasive and life-threatening infection through septic emboli, particularly to the lungs. Level of evidence Level III.

Soft tissue chondroma is a rare benign tumour, which is generally seen in adult. It consists of islands of heterotopic cartilaginous tissue and most localised on the hands and the feet. The hypothesis that microtrauma is involved in the aetiology of this condition has yet to find any factual support.To report two paediatric cases of soft tissue chondroma.The first is a soft tissue chondroma of the posterior aspect of the left axilla in a 3-year-old boy. CT scans showed a spherical fatty density soft tissue mass without evident calcifications, attaching the infraspinous muscle. The second patient is a 9-year-old girl presented with a right auricular finger soft tissue chondroma. Radiographs showed several punctuated calcifications with adjacent bone scalloping. MRI revealed a lobulated soft tissue mass attaching the flexor tendons. The tumours were entirely removed. Histological examination showed cartilaginous tissue in both cases. At follow-up, the patients had good functions without evidence of recurrence.Simple excision should suffice to treat soft tissue chondroma but care should be taken to make the excision complete if recurrence are to be avoided.

Shoulder sequelae of obstétrical brachial plexus palsy put a different problem of coverage according to the age of the patients and the presence or not of ostéo-articular deformations. At an advanced age and in the presence of ostéo-articular deformations, the muscles liberation and transfers tendineux only are insufficient for the restoring of a satisfactory function to the paralytic shoulder.The purpose of this study is to report an original technique by the association of libertation of retracted muscles and a humeral osteotomy to improve the abduction and to acquire an active external rotation in internal rotation retraction of the shoulder sequelae of obstétrical brachial plexus palsy.This retrospective study concerned twelve patients admitted in the service of Childish Orthopaedics of Children's hospital of Tunis between 1997 and 2003. The average age of the patients are 11 years. All the patients have a proximal humeral osteotomy above the deltoïdien V with a desinsertion of the Subscapularis and to the transfer of the Latissimus Dorsi and Teres Major, realized by a single posterior approch.After a mean follow up of 48 month a frank aesthetic and functional improvement was noted in every case.The importance of retraction for an advanced age, made that an humeral osteotomy of external derotation is necessary. Have a practice above the deltoïdien V it allows to improve at the same time the external rotation and the abduction due to the lateral translation of the deltoid. This last one is strengthen by the désinsertion of a retracted Subscapularis and levying of the co-contractions of the Latissimus Dorsi and Teres major with the deltoid almost constant.

Reduction of developmental dislocation of the hip is difficult to achieve in children after walking age and particularly in older children. In fact, at this age the important retraction of the muscles around the hip associated with a marked acetabular dysplasia and elongation of the joint capsule explain the difficulty and instability of reduction and the frequency of complications. In this study we reviewed retrospectively the clinical and radiological results of 26 developmental dislocations of the hip treated by open reduction, pelvic osteotomy and femoral shortening in 21 children aged more than 5 years. Age at surgery ranged from 5 to 11 years (mean 7.5 years) with a follow-up of 1 to 8 years (mean 2 years 7 months). According to the clinical classification of MC Kay, 17 hips had a good result while 9 hips had a fair or poor result. According to the Severin classification system 18 hips had an excellent and good radiological result. Ten hips developed an avascular necrosis of the femoral head following the reduction.

A retrospective study realised over 10 years in the orthopaedic unit of the children's hospital of Tunis allowed to collect 206 cases of osteomyelitis and arthritis in infant (3 months--3 years old). In 74.6% of the cases, infection involved the joint. There is a single focus of the infection in 92.6% of the cases, more often at the lower limbs. The pathogen has been isolated in 33% of the cases. Staphylococcus aureus (52 %) is the more frequent pathogen, especially in osteomyelitis. Enterobateria (16%), Streptococcus (17.7%) (Streptococcus pneumonia: 10.7%), and Hemophylus influenzea (5.3%) were often isolated in arthritis.

Introduction L’osteomyelite aigue de l’ischion est une entite rare. Le tableau clinique est souvent atypique rendant le diagnostic difficile. Nous rapportons une serie de sept cas d’osteomyelites de l’ischion afin d’etudier les particularites cliniques et para-cliniques de cette localisation osteomyelitique. Materiel et Methodes Il s’agissait de sept garcons ayant un âge moyen de neuf ans et demi avec des extremes de cinq ans a 12 ans. Dans un cas, l’atteinte etait bilaterale. On a note un retard de prise en charge avec un delai moyen symptomes-consultation de cinq jours et un delai moyen consultation-hospitalisation de huit jours. Le tableau clinique n’etait pas specifique. Le syndrome febrile n’etait pas present dans tous les cas. On a note une fievre a 38,6C en moyenne et la temperature n’etait superieure a 38,5C que dans quatre cas. La symptomatologie clinique se resumait a un syndrome douloureux de la hanche dans cinq cas. La douleur etait abdomino-pelvienne dans deux cas. L’examen physique initial n’a note la douleur exquise ischiatique que dans deux cas. — Le diagnostic de l’osteomyelite de l’ischion a ete retenu comme suit ; — dans 4 cas : en se basant sur le resultat d’IRM et en isolant le germe pathogene ; — dans 1 cas : en se basant sur la radiographie standard initiale qui a montre une geode au niveau de l’ischion, l’IRM qui a montre des signes en faveur de l’osteomyelite de l’ischion et la chirurgie qui a permis d’evacuer une collection purulente ; — dans 2 cas : en se basant sur le resultat de la scintigraphie qui a montre une hyperfixation au niveau de la branche ischio-pubienne. Le traitement etait medical dans un cas et medico-chirurgical dans six cas. Resultats Nos resultats ont ete juges avec un recul moyen de trois ans avec des extremes de un a dix ans : Tous les malades ont recupere une fonction normale. Aucune complication n’a ete observee. Discussion Les osteomyelites hematogenes pelviennes sont rares (2 a 11 % des osteomyelites). La localisation au niveau de l’ischion est exceptionnelle. Les auteurs discutent les particularites, cliniques, para-cliniques et therapeutiques de cette localisation osteomyelitique. Conclusion Devant une boiterie douloureuse et febrile chez un enfant, la palpation des reperes osseux au niveau du bassin au cours de l’examen physique, est capitale afin de detecter une eventuelle osteomyelite pelvienne. L’IRM est d’un grand d’apport pour le diagnostic precoce de l’osteomyelite de l’ischion.