Search

Trunk movements during quiet and deep breathing in untreated and in operated patients with scoliosis are not well defined. To evaluate sagittal and transverse plane cross-sectional variations of the trunk during quiet and deep breathing by optical reflective motion analysis (ORMA) in children with scoliosis. Twenty-one patients were divided into three groups: normal subjects (A; n = 6), subjects with untreated scoliosis50° (B; n = 7) and operated patients (C; n = 8). Standing and sitting height, T1-T12 and L1-L5 length, arm span, chest perimeter, weight and BMI were recorded. Trunk movements of all patients, during quiet and deep breathing, were measured with a 10-camera 3D ORMA system (82 markers) with the subjects in a standard standing position. Groups were comparable with respect to age, sex, height, arm span and weight (P 0.05). Significant differences were found in Cobb angle, chest perimeter and BMI (P 0.05). Trunk sagittal and transverse plane movements during quiet and deep breathing decreased significantly in group B and group C when compared to group A (P 0.05). Surgery does not completely eliminate sagittal and transverse plane kinematics, although the spine is rendered more rigid. This preliminary study involving a relatively limited number of patients outlines ORMA is a useful tool for analyzing sagittal and transverse plane motion abnormalities of the trunk. Trunk kinematics was altered during breathing in unoperated patients with scoliosis50°. Operated subjects had sagittal plane trunk kinematics closer to normal subjects, although changes were less pronounced at the level of the convex side.

BACKGROUND In patients with untreated scoliosis or in those with posterior spinal instrumented fusion (PSF), the movements of neither the thoracic cage (ThC) nor the abdomen (ABD) during quiet and deep breathing have been well defined in the literature. The purpose of this study was to evaluate kinematic variations in the ThC and ABD during quiet and deep breathing by optical reflective motion analysis (ORMA) in children with scoliosis. METHODS The study included 6 healthy children (group A), 7 subjects with untreated scoliosis over 50 degrees (group B), and 8 patients with scoliosis treated by PSF (group C). After anthropometric measurements (standing height, sitting height, arm span, chest perimeter, body weight, body mass index, T1-T12, and L1-L5 length) were obtained, the movements of subjects during quiet and deep breathing were measured with a 10-camera 3-dimensional ORMA system (82 markers) with the subjects in a standard standing position. RESULTS No significant differences were observed in sex, age, weight, height, or arm span (P>0.05). Significant differences were observed in the chest perimeter, Cobb angle, and body mass index (P

Background/purpose Intracranial calcifications have been identified in many neurological disorders. To our knowledge, however, such findings have not been described in cartilage-hair hypoplasia – anauxetic dysplasia spectrum disorders (CHH-AD), a group of conditions characterized by a wide spectrum of clinical manifestations. Methods/results We report a 22-year old female patient, diagnosed with this disorder during her first year of life, and in whom bilateral intracranial calcifications (frontal lobes, basal ganglia, cerebellar dentate nuclei) were discovered by brain MRI at the age of 17 years. Conclusion The etiology of this finding remains unclear. Some causes of such deposits can be of a reversible nature, thus prompting early recognition although their consequences on clinical outcome remain mostly unknown.

Horizontal gaze palsy with progressive scoliosis (HGPPS) is a rare autosomal recessive disorder characterized by the absence of conjugate horizontal eye movements, and progressive scoliosis developing in childhood and adolescence, caused by mutations in the ROBO3 gene which has an important role in axonal guidance and neuronal migration. We describe two female children aged 12 years and 18 months, with progressive scoliosis, in whom the neurological examination showed absent conjugate horizontal eye movements, but preserved vertical gaze and convergence. Cerebral Magnetic resonance imaging findings included pontine hypoplasia, absent facial colliculi, butterfly configuration of the medulla and a deep midline pontine cleft, while Diffusion tensor imaging (DTI) maps showed the absence of decussating ponto-cerebellar fibers and superior cerebellar peduncles. Somatosensory and motor evoked potential studies demonstrated ipsilateral sensory and motor responses. The diagnosis was confirmed by the identification of bi-allelic mutations in the ROBO3 gene.

The aim of this study is to quantify the changes in the sagittal alignment of the cervical spine in patients with adolescent idiopathic scoliosis following posterior spinal fusion. Patients eligible for study inclusion included those with a diagnosis of mainly thoracic adolescent idiopathic scoliosis treated by means of posterior multisegmented hook and screw instrumentation. Pre and post-operative anterior-posterior and lateral radiographs of the entire spine were reviewed to assess the changes of cervical sagittal alignment. Thirty-two patients (3 boys, 29 girls) met the inclusion criteria for the study. The average pre-operative cervical sagittal alignment (CSA) was 4.0° ± 12.3° (range -30° to 40°) of lordosis. Postoperatively, the average CSA was 1.7° ± 11.4° (range -24° to 30°). After surgery, it was less than 20° in 27 patients (84.4%) and between 20° and 40° in 5 patients (15.6%). The results of the present study suggest that even if rod precontouring is performed and postoperative thoracic sagittal alignment is restored, improved or remains unchanged after significant correction of the deformity on the frontal plane, the inherent rigidity of the cervical spine limits changes in the CSA as the cervical spine becomes rigid over time.

Case records and radiological investigations of six children with benign fibrous histiocytoma were studied retrospectively. BFH occurred in the femur (n = 2), tibia (n = 2) and fibula (n = 2). Clinically, patients reported pain from the lesion lasting several months (mean 6 months). The pain was not associated with pathological fracture in any patient. On X-rays, the lesions appeared as lytic and sharply demarcated with a sclerotic rim and fine trabeculations. The reported cases were located in the metaphysis and the diaphysis of the long bones. The tumour was restricted to bone, without periosteal or soft tissue reaction. Treatment consisted of careful intralesional curettage of the lesion; the defect was thereafter filled with bone bank graft or injectable phosphocalcic cement. The length of follow-up ranged from 24 months to 4.75 years (mean 35.2 months). One case presented with recurrence of the disease and required successful repeat intralesional curettage. Benign fibrous histiocytoma is probably underestimated among patients less than 20 years of age. This diagnosis should be considered in any child or teenager who presents with a non-ossifying fibroma accompanied by unexplainable pain or a rapid growing. Surgery restricted to the osteolytic lesion seems sufficient to achieve bone healing.

The strategy for the treatment of idiopathic scoliosis depends essentially upon the magnitude and pattern of the deformity, and its potential for progression. Treatment options include observation, bracing and/or surgery. During the past decade, several studies have demonstrated that the natural history of adolescent idiopathic scoliosis can be positively affected by nonoperative treatment, especially bracing. Other forms of conservative treatment, such as chiropractic or osteopathic manipulation, acupuncture, exercise or other manual treatments, or diet and nutrition, have not yet been proven to be effective in controlling spinal deformity progression, and those with a natural history that is favorable at the completion of growth. Observation is appropriate treatment for small curves, curves that are at low risk of progression, and those with a natural history that is favorable at the completion of growth. Indications for brace treatment are a growing child presenting with a curve of 25°-40° or a curve less than 25° with documented progression. Curves of 20°-25° in patients with pronounced skeletal immaturity should also be treated. The purpose of this review is to provide information about conservative treatment of adolescent idiopathic scoliosis. Indications for conservative treatment, hours daily wear and complications of brace treatment as well as brace types are discussed.

The aim of this study is to describe the radiological changes in rib-vertebral angles (RVAs), rib-vertebral angle differences (RVADs), and rib-vertebral angle ratios (RVARas) in patients with untreated right thoracic adolescent idiopathic scoliosis and to compare with the normal subjects. The concave and convex RVA from T1 to T12, the RVADs and the RVARas were measured on AP digital radiographs of 44 female patients with right convex idiopathic scoliosis and 14 normal females. Patients were divided into three groups: normal subjects (group 1), scoliotic patients with Cobb's angle equal or

Resume La boiterie aigue de l’enfant est un motif de consultation frequent aux urgences. La leucemie aigue est une des etiologies rarement rencontrees dans l’activite du chirurgien orthopediste. De plus, sa presentation clinique est peu caracteristique, source de possibles retards diagnostiques. Pour ces raisons, nous rapportons notre experience de quatre cas d’enfants initialement vus aux urgences pediatriques pour boiterie, symptome inaugural d’une leucemie aigue. La principale caracteristique des douleurs des membres etait leur variabilite. Le bilan radiographique a toujours ete normal. Les anomalies du sang peripherique etaient initialement absentes dans un cas et les cellules blastiques absentes dans deux cas. Le praticien doit retenir que la normalite des differents examens paracliniques ne permet pas d’exclure le diagnostic de leucemie aigue, que toute baisse d’une lignee hematopoietique doit conduire a realiser un myelogramme et que les examens paracliniques, dont l’hemogramme, doivent etre repetes en l’absence de diagnostic et d’amelioration ou de guerison confirmee dans le temps.

We describe a case of multiple intra-articular masses in the glenohumeral joint of a 15-year-old patient. The patient was treated with arthroscopic excision of the masses and synovectomy. Histological and immunohistochemical studies were consistent with those of a nodular fasciitis. Follow-up examination did not reveal recurrence at 6 months. In this article we report the first case of articular nodular fasciitis in the glenohumeral joint with unusual imaging findings.

The PTEN hamartoma tumor syndrome, manifestations of which include Cowden disease and Bannayan-Riley-Ruvalcaba syndrome, is caused by various mutations of the PTEN gene located at 10q23. Its major criteria are macrocephaly and a propensity to develop breast and thyroid cancers as well as endometrial carcinoma. Minor diagnostic criteria include hamartomatous intestinal polyps, lipomas, fibrocystic disease of the breasts, and fibromas. Mutations of PTEN can also be found in patients with Lhermitte-Duclos disease (dysplastic gangliocytoma of the cerebellum). The authors report the case of a 17-year-old girl who had a severe cyanotic cardiac malformation for which surgery was not advised and a heterozygous missense mutation (c.406T>C) in exon 5 of PTEN resulting in the substitution of cysteine for arginine (p.Cysl36Arg) in the protein, which was also found in her mother and sister. The patient presented in the pediatric emergency department with severe spastic paraparesis. A magnetic resonance imaging study of the spine showed vertebral hemangiomas at multiple levels, but stenosis and compression were maximal at level T5-6. An emergency T5-6 laminectomy was performed. The decompression was extremely hemorrhagic because the rapid onset of paraparesis necessitated prompt treatment, and there was no time to perform preoperative embolization. The patient's postoperative course was uneventful with gradual recovery. This represents the first report of an association of a PTEN mutation and multiple vertebral angiomas. The authors did not treat the remaining angiomas because surgical treatment was contraindicated without previous embolization, which in itself would present considerable risk in this patient with congenital cyanotic heart disease.

We report 4 cases of nutcracker fractures of the cuboid resulting from equestrian sport in pediatric population. These lesions are often consistent with a trauma in forced abduction of the forefoot. The particular mechanism of the cuboid fracture due to horseback riding in children is discussed. The methods used to radiographically evaluate the compression fracture of the cuboid and its associated injuries are presented. Left untreated, these fractures can lead to severe alterations in foot mechanics and function, such as to severe pain. In addition, the surgical treatment to correct the nutcracker fracture of the cuboid in our patients is presented.

In order to avoid the morbidity from autogenous bone harvesting, bone graft substitutes are being used more frequently in spinal surgery. There is indirect radiological evidence that bone graft substitutes are efficacious in humans. The purpose of this four-case study was to visually, manually, and histologically assess the quality of a fusion mass produced by a collagen hydroxyapatite scaffold impregnated with autologous bone marrow aspirate for posterolateral fusion. Four patients sustained an acute thoracolumbar fracture and were treated by short posterior segment fusion using the AO fixateur interne. Autologous bone marrow (iliac crest) impregnated hydroxyapatite-collagen scaffold was laid on the decorticated posterior elements. Routine implant removal was performed after a mean of 15.3 months (12–20). During this second surgery, fusion mass was assessed visually and manually. A bone biopsy was sent for histological analysis of all four cases. Fusion was confirmed in all four patients intraoperatively and sagittal stress testing confirmed mechanical adequacy of the fusion mass. Three out of the four (cases 2–4) had their implants removed between 12 and 15 months after the index surgery. All their histological cuts showed evidence of newly formed bone and presence of active membranous and/or enchondral ossification foci. The last patient (case 1) underwent implant removal at 20 months and his histological cuts showed mature bone, but no active ossification foci. This four-case report suggests that the fusion mass produced by a mineralized collagen matrix graft soaked in aspirated bone marrow is histologically and mechanically adequate in a thoracolumbar fracture model. A larger patient series and/or randomized controlled studies are warranted to confirm these initial results.

Low protein intake is highly prevalent among orthopaedic elderly patients. We studied the effects of an isocaloric low protein diet on the resistance to pull-out of titanium rods implanted into rats proximal tibia. Isocaloric low protein intake impairs titanium implant osseointegration, with a decreased strength needed to completely loose the implant and altered bone microarchitecture in its vicinity.Low protein intake is highly prevalent among elderly patients in orthopaedic wards and could retard fracture healing. It was previously shown that reduced protein intake decreases bone strength. Whether dietary protein intake could influence titanium implant osseointegration is unknown. We studied the effects of an isocaloric low protein diet on the resistance to pull-out of titanium rods implanted into rats proximal tibia.Forty-eight 11-month-old female rats were fed isocaloric diets containing 2.5% (low protein) or 15% (normal protein) casein from 2 weeks before the implantation of a 1-mm-diameter cylindrical titanium rod in the proximal metaphysis of each tibia. Four, 6, and 8 weeks after implantation, the tibias were removed for microCT histomorphometry to quantify bone-to-implant contact and bone trabecular microarchitecture around the implant. Resistance to implant pull-out was tested by recording the maximal force necessary to completely loosen the implant.Pull-out strength was significantly lower in rats fed an isocaloric low protein diet by 6 and 8 weeks after implantation (-43%, p0.001 and -42%, p0.001, respectively) compared with rats fed a normal protein diet. Bone-to-implant contact was significantly lower in the low protein group 8 weeks after implantation (p0.05). Bone-to-implant contact and pull-out strength were correlated (r2= 0.57, p0.0001). BV/TV around the implant was 19.9 +/- 2.2% (SE) versus 31.8 +/- 3.3% (p0.05) at 6 weeks and 20.1 +/- 1.9% versus 29.8 +/- 3.2% (p0.05) at 8 weeks after implantation in the low protein and normal protein intake groups, respectively. Trabecular thickness was 96.2 +/- 3.7 versus 113.0 +/- 3.6 microm (p0.01) at 6 weeks and 101.4 +/- 2.7 versus 116.2 +/- 3.3 microm (p0.01) at 8 weeks in the corresponding groups. In a structure model index analysis, there was a significant shift to a more rod-like pattern in the low protein diet groups. All these changes were associated with lower plasma IGF-I levels.Isocaloric low protein intake impairs titanium implant osseointegration, with decreased strength needed to completely loosen the implant and altered bone microarchitecture in the vicinity of the implant.

Camurati–Engelmann disease (CED) is a rare autosomal dominant disease characterized by progressive bilateral symmetric sclerosis and thickening of long bone diaphyses (1). Diagnosis is based on phy...

Objective From a dataset of clinical assessments and gait analysis, this study was designed to determine which of the assessments or their combinations would most influence a low gait index (i.e., severe gait deviations) for individuals with cerebral palsy. Design A retrospective search, including clinical and gait assessments, was conducted from August 2005 to September 2009. Population One hundred and fifty-five individuals with a clinical diagnosis of cerebral palsy (CP) (mean age (SD): 11 (5.3) years) were selected for the study. Method Quinlan's Interactive Dichotomizer 3 algorithm for decision-tree induction, adapted to fuzzy data coding, was employed to predict a Gait Deviation Index (GDI) from a dataset of clinical assessments (i.e., range of motion, muscle strength, and level of spasticity). Results Seven rules that could explain severe gait deviation (a fuzzy GDI low class) were induced. Overall, the fuzzy decision-tree method was highly accurate and permitted us to correctly classify GDI classes 9 out of 10 times using our clinical assessments. Conclusion There is an important relationship between clinical parameters and gait analysis. We have identified the main clinical parameters and combinations of these parameters that lead to severe gait deviations. The strength of the hip extensor, the level of spasticity and the strength of the tibialis posterior were the most important clinical parameters for predicting a severe gait deviation.

Objective. To examine growth factor responses of human articular chondrocytes in aging and development. We have previously established a growth factor response profile for adult human articular chondrocytes and shown that transforming growth factor β (TGFβ) is the most potent mitogen among a variety of factors tested. Methods. Chondrocytes were isolated from human articular cartilage obtained from donors ages 11–83 years and tested in primary culture for proliferative responses to serum and recombinant preparations of the major chondrocyte growth factors. Proliferation was measured by 3H-thymidine incorporation and cell counting. Skeletal maturity of the young donors was determined by radiographic assessment of Risser's index. Results. Chondrocytes showed a continuous age-related decline in the proliferative response to serum. Analysis of recombinant growth factors showed that with increasing donor age, there was a decrease in the levels of DNA synthesis in response to all factors tested. In chondrocytes from adult donors, there was no change in the relative potencies of the different growth factors. The decrease in the levels of DNA synthesis as measured by 3H-thymidine incorporation corresponded to a reduced rate of in vitro cell replication with increasing donor age. In addition to the quantitative changes in the proliferative responses of chondrocytes with increasing age, there was a qualitative change in the pattern of growth factor responses during development. Cells from young donors (ages 10–20) responded better to platelet-derived growth factor, AA chain homodimer (PDGF-AA) than to TGFβ1, while the inverse pattern was seen in cells from adult donors. This decrease in the response to PDGF-AA was significantly correlated with increasing skeletal maturity. Conclusion. Chondrocyte growth factor responsiveness shows qualitative changes during development, and after skeletal maturity, there is a profound decline in the levels of DNA synthesis and cell replication in response to the known chondrocyte growth factors.

A six-year-old girl sustained a Monteggia type-I equivalent fracture of the right forearm. We describe the method of treatment of this rare fracture and its outcome.

This study evaluated the outcome of severe cerebral palsy patients (Gross Motor Function Classification System level IV and V) treated by simultaneous percutaneous pelvic osteotomy and intertrochanteric varus shortening osteotomy for hip subluxation or dislocation between 2002 and 2011. Twenty-four patients (30 hips) with an average age of 9.4 years (5-16.5) were reviewed at a mean follow-up of 35.9 months (6-96). Percutaneous pelvic osteotomy lasted on average 30 min/patient per side (25-40) and was always performed through a skin incision of 2-3 cm. The migration percentage and acetabular angle were assessed on plain radiographs. The mean Reimers' migration percentage improved from 67.1% (42-100) preoperatively to 7.7% (0-70) at the last follow-up and the mean acetabular angle improved from 31.8° (22-48) to 15.7° (5-27). Five patients presented complications: one redislocation, one bone graft dislodgement, and three with avascular necrosis of the femoral head. This study should be considered as a pilot study. These results indicate that this combined approach is an effective, reliable, and minimally invasive alternative method for the treatment of spastic dislocated hips in severe cerebral palsy patients with an outcome similar to standard techniques reported in the literature.

Forearm fractures are common in the pediatric population and are mostly treated by cast immobilization. The purposes of this study were first to determine whether forearm fractures in adolescents are associated with abnormal bone mineral density (BMD) or content (BMC) at the time of fracture, and second, to quantify the bone mineral loss at various sites due to cast-mediated immobilization.This longitudinal case-control study recruited 50 adolescents (age, 12.8 ± 1.8 y) who underwent cast-mediated immobilization for a forearm fracture and 50 healthy controls (13.0 ± 1.8 y). Using 2 dual-energy x-ray absorptiometries, BMD and BMC were measured at various skeletal sites (total body, lumbar spine, total upper limb, and forearm) at fracture time and at cast removal.At the fracture time, BMD/BMC Z-scores at the lumbar spine and areal BMD at the peripheral wrist were not different among the injured and the healthy subjects. At cast removal, significant BMD decreases were observed in adolescents with fracture at the level of the radial and the ulnar diaphyses (-5.6% and -3.8%, respectively) and the total upper limb (-5.6%) compared with the noninjured side. Significant decreases in the BMC values were observed at the level of the radial diaphysis (-6.4%), ultradistal ulna (-10.2%), total upper limb, and total ulna (-8.2% and -4.9%, respectively).These data demonstrate that total body, lumbar spine, or wrist bone mineral mass and density (BMC and BMD) are not reduced at the fracture time in adolescents sustaining a first episode of upper limb fracture when compared with healthy subjects. These findings suggest that forearm fractures are not related to osteopenia in youth. In addition, cast-mediated immobilization results in a significant bone mineral loss at the upper limb, which may explain the increased risk of sustaining a second fracture. Finally, bone callus formation may interfere when assessing bone mineral mass after cast removal and may lead to an erroneous underestimation of bone mineral mass decrease.Level IV.

Hereditary spastic paraplegia (HSP) and spastic diplegia (SD) patients share a strong clinical resemblance. Thus, HSP patients are frequently misdiagnosed with a mild form of SD. Clinical gait analysis (CGA) has been highlighted as a possible tool to support the differential diagnosis of HSP and SD. Previous analysis has focused on the lower-body but not the upper-body, where numerous compensations during walking occur. The aim of this study was to compare the full-body movements of HSP and SD groups and, in particular, the movement of the upper limbs. Ten HSP and 12 SD patients were evaluated through a CGA (VICON 460 and Mx3+; ViconPeak(®), Oxford, UK) between 2008 and 2012. The kinematic parameters were computed using the ViconPeak(®) software (Plug-In-Gait). In addition, the mean amplitude of normalised (by the patient's height) arm swing was calculated. All patients were asked to walk at a self-selected speed along a 10-m walkway. The mean kinematic parameters for the two populations were analysed with Mann-Whitney comparison tests, with a significant P-value set at 0.05. The results demonstrated that HSP patients used more spine movement to compensate for lower limb movement alterations, whereas SD patients used their arms for compensation. SD patients had increased shoulder movements in the sagittal plane (Flexion/extension angle) and frontal plane (elevation angle) compared to HSP patients. These arm postures are similar to the description of the guard position that toddlers exhibit during the first weeks of walking. To increase speed, SD patients have larger arm swings in the sagittal, frontal and transversal planes. Upper-body kinematics, and more specifically arm movements and spine movements, may support the differential diagnosis of HSP and SD.

Leg or ankle fractures occur commonly in the pediatric population and are primarily treated with closed reduction and cast immobilization. The most predictable consequences of immobilization and subsequent weight-bearing restriction are loss of bone mineral mass, substantial muscle atrophy, and functional limitations. The purposes of this study were to determine if lower-limb fractures in adolescents are associated with abnormal bone mineral density or content at the time of fracture, and to quantify bone mineral loss at various sites due to cast-mediated immobilization and limited weight-bearing.We recruited fifty adolescents aged ten to sixteen years who had undergone cast immobilization for a leg or ankle fracture. Dual x-ray absorptiometry scans of the total body, lumbar spine, hip, leg, and calcaneus were performed at the time of fracture and at cast removal. Patients with a fracture were paired with healthy controls according to sex and age. Values at baseline and at cast removal, or at equivalent time intervals in the control group, were compared between groups and between the injured and uninjured legs of the adolescents with the fracture.At the time of fracture, there were no observed differences in the bone mineral density or bone mineral content Z-scores of the total body or the lumbar spine, or in the bone mineral density Z-scores of the calcaneus, between the injured and healthy subjects. At cast removal, bone mineral parameters on the injured side were significantly lower than those on the uninjured side in the injured group. Differences ranged from -5.8% to -31.7% for bone mineral density and from -5.2% to -19.4% for bone mineral content. During the cast period, the injured adolescents had a significant decrease of bone mineral density at the hip, greater trochanter, calcaneus, and total lower limb as compared with the healthy controls.Lower-limb fractures are not related to osteopenia in adolescents at the time of fracture. However, osteopenia does develop in the injured limb during cast immobilization for fracture treatment. Further investigation is required to determine if the bone mineral mass will return to normal or if a permanent decrease is to be expected, which may constitute a hypothetical risk of sustaining a second fracture.

Patients with cerebral palsy, syndromes, myopathies, and other forms of neurological impairment can develop planovalgus foot deformity of variable degrees of severity. Several techniques have already been described to resolve the deformity with variable results. Talonavicular arthrodesis is a well-known technique in adult patients, but to our knowledge, it has not been described in children with neurological impairment.We performed a retrospective chart and radiographic review of 18 neurological patients (10 boys, 8 girls) with a mean age of 11.3 ± 2.6 years (range, 7 to 19 y) who underwent talonavicular arthrodesis for flat foot deformity between 1998 and 2009, at our center.Of a total of 29 feet, talonavicular arthrodesis was judged satisfactory in 28 feet, whereas 1 had unsatisfactory results according to the Yoo clinical outcome scoring scale. Subjective observations reported that 3 feet from 2 patients were painful preoperatively and none after last follow-up. Functionally, 2 of 13 patients were able to stop using braces after surgery. The significant improvement achieved postoperatively in radiographic measurement angles was maintained at last follow-up without any loss of angle correction.Talonavicular arthrodesis seems to achieve a reliable hind foot fixation in flat foot in patients with neurological impairment.Case series.

Osteoarticular infections caused by Kingella kingae are characterized by mild-to-moderate clinical and biologic inflammatory signs that are different from those caused by Gram-positive cocci. A combined score was built to find the best model to predict K. kingae osteoarticular infections by using the following 4 variables: body temperature

Developmental dysplasia of the hip and idiopathic clubfoot are common musculoskeletal conditions in the pediatric orthopedic population. Although ultrasound or radiographic screening is generally recommended to rule out occult hip dysplasia, it has been suggested that children with clubfoot should no longer be screened. We report two cases of newborns with unilateral clubfoot and bilaterally stable hips that developed unilateral hip dysplasia on the same side as the foot deformity during clubfoot treatment. All cases previously reported in the literature are reviewed. We recommend systematic hip ultrasound screening in patients with idiopathic clubfoot. A second hip ultrasound or a pelvis radiograph, if the ossific nucleus has appeared, should be performed after completion of the clubfoot treatment if clinical examination is abnormal.

STUDY DESIGN Retrospective review. OBJECTIVE The aim of this study is to describe the radiologic changes in rib-vertebral angles (RVAs), rib-vertebral angle differences (RVADs), and rib-vertebral angle ratios (RVARas) in patients with Lenke type 1 main thoracic adolescent idiopathic scoliosis treated by observation, bracing, or posterior fusion and instrumentation, and to compare these with normal individuals. SUMMARY OF BACKGROUND DATA The RVA measurement has been shown to be a valid and reproducible method and its asymmetries are related to age, sex, and laterality patterns of the curvature. However, studies of RVA and RVAD in patients with adolescent idiopathic scoliosis are scarce and there are no data regarding the assessment of the ratio between concave and convex RVA. METHODS A retrospective chart and radiograph review was carried out for 66 consecutive adolescent female patients with Lenke type 1 main thoracic idiopathic scoliosis and 14 normal counterparts. Patients were divided into 5 groups: normal individuals (group 1); scoliotic patients with Cobb angle

Purpose Synovial sarcoma (SS) is an aggressive soft-tissue tumor noted for late local recurrence and metastasis. This study investigates the long-term outcome of SS in patients of pediatric age and evaluates potential prognostic factors for SS. Methods We performed a retrospective review of 13 SS cases in patients younger than 20 years at the time of diagnosis who had a minimum follow-up of 10 years. The mean follow-up for living patients ( n = 8) was 20.1 years (12.1–27.6) and for nonsurvivors ( n = 5) 4.9 years (range: 2.6–9.3). Nine patients had unplanned excisions (69%), of which 6 (67%) were performed prior to their referral. Re-excisions were necessary in all 13 patients. The factors sex, tumor site, tumor size, tumor grade, histological subtype, fusion type, and type of treatment were evaluated for their prognostic value. Results Only 2 patients (15%) met the criteria of adequate tumor treatment. Overall, the 5- and 10-year survival rates were 77 and 61%, respectively. The mean time until a local recurrence ( n = 5) was 3.2 years (range: 0.7–10.2), while there was a mean time of 2.1 years until the occurrence of late metastases ( n = 5; range: 0.8–4.8). A high tumor grade and having a tumor in the trunk were adverse factors in terms of overall, local recurrence-free, and metastasis-free survival. Patients with wide resections or amputations had fewer local recurrences than patients with marginal or intralesional resections. Conclusion Inadequate primary excision of SS results in incomplete excision in the majority of cases. The tumor site, size, and histological grade should be considered when determining a risk-adapted treatment for SS, and wide surgical excision is the surgical intervention of choice. While local recurrence and late metastases appear to occur after a shorter time period in pediatric patients than in adults, in view of the tendency for late recurrence and metastasis with SS, follow-up should be at least 10 years.

MacFarland fracture is a joint fracture of the ankle in children involving the medial malleolus (Salter-Harris type III or IV). These fractures are acknowledged to have poor prognosis because of the risk of misalignment due to the development of an epiphysiodesis bridge. Current recommended treatment for a displacement of ≥ 2 mm is open reduction through an arthrotomy with screw fixation. This study aimed to evaluate functional and radiologic results of a less-invasive surgical technique consisting of closed reduction, arthrographic control of fracture reposition, and percutaneous screw fixation.Retrospective analysis of 12 cases of children with MacFarland fractures who underwent percutaneous screw fixation with intraoperative arthrography. Data collected for each child included age, sex, radiologic Salter-Harris classification of medial and lateral malleolus fractures, fracture gap before and after treatment, intraoperative and postoperative complications, and length of follow up. Results were evaluated according to the 3 outcome categories according to the classification by Gleizes and based on clinical and radiologic criteria.There were 7 boys and 5 girls with an age range of 10 to 15 years (average, 12 y 6 mo). Average follow-up was 18 months (range: 9 to 57 mo). Medial malleolus fracture was Salter-Harris type III in 7 patients and type IV in 5. There were 9 Salter-Harris type I fractures and 1 type II at the level of the distal fibular physis. The mean preoperative gap was 2.8 mm (1.9 to 4 mm). Fracture fixation was performed with 2 screws in 9 patients and 1 screw in 3 patients. Mean surgical time was 58 minutes (45 to 75 min). The mean postoperative articular gap was 0 mm in 8 patients, inferior to 1 mm in 3 patients, and 2 mm in 1 patient. At the time of last follow-up, the outcome was considered good in all but 1 patient.Closed reduction combined with ankle arthrography followed by percutaneous osteosynthesis is an interesting and less invasive safe surgical alternative to classic open reduction and internal fixation of displaced MacFarland fractures.Therapeutic study, level IV.

BACKGROUND: Deleterious effects of lower limb immobilization in adults have been well described and suggest that altered muscle strength was not fully recoverable after rehabilitation. In this study, we hypothesized that the same significant differences in strength and power performances between the injured and noninjured leg are foreseeable 18 months after a lower limb fracture in teenagers, and between injured adolescents and healthy controls. METHODS: The effects of cast immobilization on the strength and power performance were evaluated 18 months after a lower limb fracture in 39 injured teenagers who were paired with healthy controls. Strength and power performance were assessed during a single-leg vertical jump test using a force platform. RESULTS: At 18 months, strength performance in injured teenagers was similar in both lower limbs. A significant difference was found between injured and noninjured legs for maximal muscular power measurement. However, the limb symmetry index was superior to 85% for maximal muscular power, which should be considered as normal. Limb asymmetries greater than 15% for muscular strength and power were more frequent in injured teenagers than in noninjured children and adolescents, but the difference was statistically significant only for the mean muscle power (P=0.0003). CONCLUSIONS: These findings show that the recovery of muscular strength and power is foreseeable after a lower limb fracture in the pediatric population, even if a greater percentage of injured teenagers was found to have limb asymmetries greater than 15% for mean muscular power 18 months after trauma compared with the healthy controls. LEVEL OF EVIDENCE: Level III, case-control study.

BACKGROUND: Radial neck fractures are a common injury in children as a result of a fall on an extended and supinated outstretched hand. METHODS: We present 2 cases of osteotomy of the neck of the radius performed in 2 children with neglected radial neck fractures. RESULTS: Preoperatively, both patients complained of pain and severely reduced mobility of the elbow. Surgery was performed at 6 weeks and 3 months, respectively, after the initial injury and the 2 children were reviewed at 6 and 16 months follow-up. Osteotomies healed within the usual time and no avascular necrosis of the radial head, proximal radioulnar synostosis, or myositis ossificans were observed. The Mayo Elbow Performance Index Score improved significantly after the operation with the 2 patients rated as excellent. CONCLUSIONS: In this small series, we present a novel technique of proximal osteotomy of the radius to correct this deformity in children. LEVEL OF EVIDENCE: Case series, level IV evidence.

Background: Synovial sarcoma (SS) is a malignant soft tissue sarcoma with a poor prognosis because of late local recurrence and distant metastases. To our knowledge, no studies have minimum follow-up of 10 years that evaluate long-term outcomes for survivors. Patients and methods: Data on 62 patients who had been treated for SS from 1968 to 1999 were studied retrospectively in a multicenter study. Mean follow-up of living patients was 17.2 years and of dead patients 7.7 years. Results: Mean age at diagnosis was 35.4 years (range 6-82 years). Overall survival was 38.7%. The 5-year survival was 74.2%; 10-year survival was 61.2%; and 15-year survival was 46.5%. Fifteen patients (24%) died of disease after 10 years of follow-up. Local recurrence occurred after a mean of 3.6 years (range 0.5-14.9 years) and metastases at a mean of 5.7 years (range 0.5-16.3 years). Only four patients were treated technically correctly with a planned biopsy followed by a wide resection or amputation. Factors associated with significantly worse prognosis included larger tumor size, metastases at the time of diagnosis, high-grade histology, trunk-related disease, and lack of wide resection as primary surgical treatment. Conclusions: In SS, metastases develop late with high mortality. Patients with SS should be followed for >10 years.

BACKGROUNG: Kingella kingae is an emerging pathogen that may be recognized as the most common bacteria responsible for osteoarticular infections (OAI) in young children. However, its diagnosis remains a challenge and thus little evoked in infants, because K. kingae is a difficult germ to isolate on solid medium, and clinical signs are often mild. The main objective of this prospective study is to describe the clinical, biologic, and radiologic features of children with OAI caused by K. kingae. In addition, we describe the usage of a new specific real-time PCR assay in children under 4 years admitted for OAI with a probe that detects 2 independent gene targets from the K. kingae RTX toxin. PATIENTS AND METHODS: All children less than 4 years admitted in our institution between January 2007 and November 2009 for suspected OAI were enrolled in this prospective study (43 cases). Age, gender, clinical signs, duration of symptoms, bone or joint involved, imaging studies, and laboratory data, including bacterial investigations, full blood count, erythrocyte sedimentation rate, and serum C-reactive protein were collected for analysis. RESULTS: Identification of the microorganism was possible for 28 cases (65.1%) yielding K. kingae in 23 cases (82.1%). Mean age of children with K. kingae OAI was 19.6 months. Less than 15% of these patients were febrile during the admission, but 46% of them presented a history of fever-peak superior to 38.5 degrees C before admission. Thirty-nine percent of the children with K. kingae OAI had normal C-reactive protein; WBC was elevated in only 2 cases, whereas 21 patients had abnormal erythrocyte sedimentation rate, and 13 abnormal platelet counts. Direct Gram staining and classical isolation methods were negative for all cases subsequently detected as K. kingae OAI by specific real-time PCR. CONCLUSION: This study confirms that K. kingae is the major bacterial cause of OAI in children less than 4 years. The real-time PCR assay, specific to the K. kingae RTX toxin, provides interesting diagnostic performance when implemented in the routine microbiologic laboratory. Needless to say, a bigger cohort is required to adequately study this new qPCR assay, but the results so far seem promising. The most important additional finding is the mild-to-moderate clinical, radiologic, and biologic inflammatory response to K. kingae infection with the result that these children present few criteria evocative of OAI. LEVEL OF EVIDENCE: II.

As the result of improved bacteriological techniques, Kingella kingae is a slow-growing Gram-negative coccobacillus that is emerging as an important cause of spondylodiscitis in children younger than 3 years of age. The high pharyngeal carrier rates of this slow-growing Gram-negative coccobacillus combined with the low incidence of identified K. kingae infections is possibly explained by a low virulence of this bacterium. The use of specific real-time polymerase chain reaction (PCR) on blood samples and throat swabs opens new prospects in the bacteriological investigations of young children suspected to have spondylodiscitis, an approach that could prevent, in the future, unnecessary invasive interventions.

There was an error in affiliation 3 for author Sophie Clement. Affiliation 3 should be: Division of Clinical Pathology, Medical School of Geneva, Geneva, Switzerland.

SummaryAcute limping in children is a common reason for consultation in pediatric emergency units. Acute leukemia is a rarely encountered disease in the orthopedic surgeon's activity. In addition, its clinical presentation is not typical and therefore is a source of possible diagnostic delay. For such reasons, there is a definite risk of undiagnosing the actual etiology of the limping episode. We report our experience with four cases of children initially seen in the pediatric emergency department for limping, as their revealing presentation of acute leukemia. The limb pain was highly variable. The radiographic work-up was always normal. Peripheral blood abnormalities were initially absent in one case and blastic cells were absent in two cases. The physician in charge should remember that paraclinical work-up normal results do not exclude a diagnosis of acute leukemia, that any drop in hematopoietic cell counts should call for a myelogram and that paraclinical exams, including the hemogram, should be repeated until a diagnosis and improvement or confirmed cure is achieved over time.Level of evidence: level IV. Diagnostic study.

Purpose The treatment of an unrecognized Monteggia lesion continues to pose a therapeutic challenge, as evidenced by the variety of surgical techniques described. Moreover, there are high complication and redislocation rates following surgery. This report concerns a surgical technique to reduce a chronic dislocation of the radial head utilizing an ulnar osteotomy and internal fixation. Methods Six consecutive cases of missed Monteggia lesions were treated in our institution between August 2001 and September 2003. Patient mean age was 6.5 (range 4–8) years, and the mean interval between injury and surgical procedure was 17 (range 1–49) months. Surgery consisted of an ulnar osteotomy with angulation and lengthening, bone grafting at the osteotomy site, and internal fixation. Open reduction of the radial head, repair or reconstruction of the annular ligament or temporary fixation of the radial head with a transarticular wire was not undertaken. Cast immobilization with the forearm in neutral rotation was maintained for 2 weeks. Results There was one case of nonunion. At an average follow-up of 3 (range 1.5–4.4) years, all patients had regained painless function of the forearm, good range of elbow and forearm motion, and maintenance of the radial head reduction. Conclusions Both angulation and elongation of the ulna are required to allow for reduction of the radial head. We do not see any indication for procedures directed at the radio-capitellar joint.

Fritz Heftia, Gernot Jundtb, Miklos D. Cserhatic, Michel Dutoitd, Gerhard U. Exnere, Andre Kaelinf, Klaus Siebenrockg, Arthur von Hochstetterh a Chefarzt, Kinderorthopadische Universitatsklinik, Universitatskinderspital beider Basel, Basel, b Leitender Arzt, Institut fur Pathologie der Universitat, Basel, c FMH Orthopadische Chirurgie und Traumatologie, Zurich, d Medecin-chef, Hopital orthopedique de la Suisse romande, Lausanne, e Orthopadische Universitatsklinik Balgrist, Zurich, f Medecin-chef, Service d’orthopedie pediatrique, Hopital des enfants, Geneve, g Chefarzt, Klinik und Poliklinik fur orthopadische Chirurgie, Inselspital, Bern, h Pathologie Institut Enge, Zurich

Summary Aneurysmal bone cyst (ABC) Aneurysmal bone cyst is a benign, destructive and aggressive lesion of the long bones, spine and pelvis, occurring mainly in children and young adults. The clinical signs, pain and quick-growing mass, are associated with radiological signs of an aggressive lesion. This suggests malignancy, but in typical cases it is really a totally benign lesion sometimes associated with genuine tumours such as chondroblastoma, osteoblastoma and (very rarely) osteosarcoma.

Summary Aneurysmal bone cyst (ABC) Aneurysmal bone cyst is a benign, destructive and aggressive lesion of the long bones, spine and pelvis, occurring mainly in children and young adults. The clinical signs, pain and quick-growing mass, are associated with radiological signs of an aggressive lesion. This suggests malignancy, but in typical cases it is really a totally benign lesion sometimes associated with genuine tumours such as chondroblastoma, osteoblastoma and (very rarely) osteosarcoma. The X-ray findings are usually typical; MRI bears out the clinical impression, but in most cases biopsy is necessary to confirm the diagnosis. Biopsy should be done with the utmost caution, due to the risk of cataclysmic bleeding. Treatment consists of curettage and bone grafting, but recurrences are frequent. Curettage associated with high-speed mechanical burr, cementation or phenol application may lessen the risk of recurrence. In selected cases broad resection can be done, provided there is no functional loss (e.g. peroneal nerve). After a resection of this kind the risk of recurrence is almost non-existent. This aggressive but benign lesion is rare and requires treatment by a specialist.

Tibial hemimelia with ectrodactyly is reported for the first time in monozygotic female twins with a positive family history for limb anomalies. This very rare autosomal dominant condition is known to be associated with a highly variable phenotype, as illustrated by the distinct clinical presentations, despite identical genotype.