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Purpose: The purpose of this study was to describe gait evolution in patients with unilateral spastic cerebral palsy (USCP) using modified Gait Profile Score (mGPS without hip rotation), Gait Variable Score (GVS), walking speed, and the observed effects of single-level surgery (SLS) after 10 years. Methods: Fifty-two patients with USCP (Gross Motor Function Classification System I) and data from two Clinical Gait Analyses (CGAs) were included. The evolution of patients’ mGPS, GVS, and walking speed were calculated. Two “no surgery” and “single-level surgery” patient categories were analyzed. Paired t-tests were used to compare the data between CGAs and as a function of treatment category. Pearson’s correlations were used to examine relationships between baseline values and evolutions in mGPS and walking speed. Results: Mean ages (SD) at first and last CGAs were 9.3 (3.2) and 19.7 (6.0) years old, respectively, with an average follow-up of 10.5 (5.6) years. Mean mGPS for the patients’ affected side was significantly lower at the last CGA for the full cohort: baseline = 8.5° (2.1) versus follow-up = 7.2° (1.6), effect size = 0.73, p Conclusions: SLS patients demonstrated a positive long-term change in gait pattern over time. The group that had undergone surgery had worse gait scores at baseline than the group that had not, but the SLS group’s last CGA scores were relatively closer to those of the “no surgery” group. Level of evidence: This was a retrospective comparative therapeutic study (level III).

Supplemental material, sj-docx-1-cho-10.1177_18632521231154975 for A 10.5-year follow-up of walking with unilateral spastic cerebral palsy by Alice Bonnefoy-Mazure, Geraldo De Coulon, Pierre Lascombes, Aline Bregou and Stéphane Armand in Journal of Children’s Orthopaedics

Pediatric displaced distal metaphyseal ulnar fractures and distal radial buckle fractures are common. However, to the best of our knowledge, their association has never been specifically reported. Thus, classification and management of this pattern remain challenging especially in young children. Distal radioulnar joint (DRUJ)'s assessment is difficult. A Galeazzi-equivalent injury should be suspected. We report the case of a 2-year-old boy who presented the above-mentioned association of forearm fractures and compare our management with actual recommendations. We would recommend a low-suspicion threshold for DRUJ's instability in young children presenting with displaced distal metaphyseal ulnar fracture associated with distal radial buckle fracture. That suspicion should raise the necessity of appropriate treatment and follow-up.

This report describes a new strategy for the care of patients with osteogenesis imperfecta, based on an interdisciplinary team working. Thereby, we aim at fulfilling three main goals: offering thorough coordinated management for all, and improving physical activity and quality of life of the patients. With rare diseases such as osteogenesis imperfecta (OI), patients and their family often suffer from inadequate recognition of their disease, poor care coordination and incomplete information. A coordinated interdisciplinary approach is one possible solution for providing both comprehensive and cost-effective care, with benefits for patient satisfaction. Poor physical activity and impaired quality of life represent a considerable burden for these patients. To better address these issues, in 2012 we created an interdisciplinary team for the management of OI patients in our University Hospital Centre (CHUV, Lausanne University Hospital,). In this article we describe the implementation of this interdisciplinary care strategy for patients suffering from OI, and its impact on their physical activity and quality of life. All patients from the French part of Switzerland were invited to join us. We proposed two complementary evaluations: the initial interdisciplinary evaluation and a yearly follow-up during a special day – the “OI day”. This day features specialised medical appointments adapted to each patient’s needs, as well as lectures and/or workshops dedicated to patients’ and families’ education. Our first aim was to propose for each patient the same management, from diagnosis to the bone health evaluation and physical therapy advice. Our second aim was to evaluate the evolution of physical activity, quality of life (measured by EQ-5D, SF-36 and a dedicated questionnaire) and satisfaction of patients and their families. Here we report both the initial and the long-term results. Since 2012, 50 patients from the French part of Switzerland received the personalised medical evaluation. All of the patients included in this study had the same initial evaluation and at least one participation in an OI Day. All patients had an adaptation of their bone acting drugs. Over a 7-year period, 62% of inactive patients started some physical activity, and 44% of patients who were not involved in any athletic activity started participating in sports. The mean EQ-5D increased from 0.73 to 0.75 (p = 0.59). The mean physical SF36 (musculoskeletal function) score was 59.09 ± 22.72 and improved to 65.79 ± 21.51 (p = 0.08), whereas it was 68.06 ± 20.05 for the mental SF36 without alteration during follow-up. The OI day was revealed to be useful, it contributed to improvement in continuity of care and helped families to better understand the OI patients’ health. Our interdisciplinary approach aimed at offering the same thorough management for all patients from the French part of Switzerland, and at improving both the physical activity and the satisfaction of the patients and their family. This report is a basis for future work focusing on the effect of bone fragility and the impact of OI on patients’ social relations.

PurposeIn case of residual hip dysplasia (RHD) in children, pelvic radiographs are sometimes insufficient to precisely evaluate the entire coverage of the femoral head, when trying to decide on the need for further reconstructive procedures.MethodsThis study retrospectively compares the bony and the cartilaginous acetabular angle of Hilgenreiner (HTE) of 60 paediatric hips on pelvic MRI separated in two groups. Group 1 included 31 hips with RHD defined by a bony HTE > 20°. Group 2 included 27 hips with a HTE ResultsThe acetabular angle ratio was statistically significantly increased in the hips with RHD with a mean value of 7.1 ± 4.7 compared to the hips in the control group presenting a mean value of 2.1 ± 1.9 (p ConclusionsThis newly introduced ratio seems to be a helpful tool to orientate the further treatment in children presenting borderline RHD.

Excessive production of reactive oxygen species (ROS) may cause endothelial dysfunction and consequently vascular disease. In the present study, the possible protective effects of sheep whey protein (SWP) from tert-butyl hydroperoxide- (tBHP-) induced oxidative stress in endothelial cells (EA.hy926) were assessed using oxidative stress biomarkers. These oxidative stress biomarkers were glutathione (GSH) and ROS levels determined by flow cytometry. Moreover, thiobarbituric acid-reactive substances (TBARS), protein carbonyls (CARB), and oxidized glutathione (GSSG) were determined spectrophotometrically. The results showed that SWP at 0.78, 1.56, 3.12, and 6.24 mg of protein mL−1increased GSH up to 141%, while it decreased GSSG to 46.7%, ROS to 58.5%, TBARS to 52.5%, and CARB to 49.0%. In conclusion, the present study demonstrated for the first time that SWP protected endothelial cells from oxidative stress. Thus, SWP may be used for developing food supplements or biofunctional foods to attenuate vascular disturbances associated with oxidative stress.

Rationale: Obturator pyomyositis is a rare condition in children. Diagnosis is often delayed because of its rarity, and the vagaries of its presentation cause it to be easily be missed. Physicians should therefore familiarize themselves with this condition and consider it as a possible differential diagnosis in patients presenting with an acutely painful hip. Inflammatory syndrome is also frequent among sufferers and the MRI is a very sensitive diagnostic tool for obturator pyomyositis. Additionally, joint fluid aspirations and blood cultures are also useful in identifying the pathogen. The appropriate antibiotic therapy provides a rapid regression of symptoms during the early stage of pyomyositis. In cases of MRI-confirmed abscess, surgical treatment is indicated. Patient concerns: Our report focuses on a case of obturator pyomyositis in a 9-year-old boy. The child was febrile for 5 days and could only manage to walk a few steps. His hip range of motion was restricted in all directions. In addition, the patient had presented pain and swelling of his right elbow for a day, with a restriction of motion in the joint. There was a clear inflammatory syndrome. A diagnosis of hip and elbow septic arthritis was suspected, and the child underwent joint aspiration of the both cited joints. The aspiration of the elbow returned pus. Conversely, no effusion was found in the hip aspiration. The administration of empiric intravenous antibiotherapy was started. Diagnoses: An MRI revealed an osteomyelitis of the ischio-pubic area associated with a subperiosteal abscess. Interventions: Subsequently, 3 days after elbow arthrotomy, a surgical treatment was performed on the patient's right hip in order to evacuate the subperiosteal abscess and muscular collection because of the persistence of the patient's symptoms and inflammatory syndrome despite susceptible intravenous antibiotics. Postsurgery the patient showed steady improvement. Lessons: Such cases demonstrate how diagnosis can be difficult because pelvic pyomyositis is often mistaken for more common pathologies such as septic arthritis, osteomyelitis, or appendicitis. This may delay the diagnosis or refer misdiagnosis. We discuss this rare infection in light of the literature with particular reference to its incidence, clinical features, bacteriological etiology, biological, and radiological presentation, and above all, its treatment.

Osteogenesis imperfecta (OI) is a rare genetic disease. Today we are able to propose an adapted and efficient management to the patients with this rare disorder (and their families) thanks to a strong collaboration of clinicians and researchers. Recent knowledge regarding the genetics of OI permits an accurate diagnosis of the specific type of OI and its own molecular mechanism, a genetic counseling for family planning and prenatal diagnosis, and in addition more targeted therapeutic options. A specific support with re-education for patients with OI is necessary and efficient. To optimize patient care, a multidisciplinary consultation is proposed at the CHUV, moreover a web site is available for patients, families and therapists: www.infomaladiesrares.ch

Objectives: Obesity in children is associated with an increased risk for fracture. The causes remain unclear and may be related to increased bone weakness during periods of intense growth or increased kinetics (when falling). The hypothesis was that obese children sustain more severe fractures compared to non-obese children, and needed more treatment under general anesthesia (GA). Methods: 6 months prospective study on obese and non-obese children presenting to the emergency room with an upper extremity long bones fractures (ULBF). The children’s activity prior to trauma was assessed with a questionnaire. The mechanism of injury, the characteristics of the fracture defined using a validated pediatric classification and the treatment modalities were compared. Results: The calculated prevalence of obesity in children with ULBF was 28%. 46 obese children aged 2 to 13 years and 119 non-obese children aged 2 to 16 years were included in the study. The risk for sustaining both bones forearm fractures was twice higher in obese children when compared to non-obese children (p=0.012). Obese children required a higher number of manipulations under GA (p=0.092). Conclusions: The prevalence of obesity in children with ULBF was higher than in the general pediatric population. There was no statistical difference between both groups in the reported level of activity, in the kinetics and in the treatment modalities. Obese children had a significantly higher risk for a combined radius-ulna fracture. Further research is needed to evaluate the relationship between obesity, bone growth and trauma.

Introduction Despite improvements in early recognition and treatment of developmental dysplasia of the hip (DDH), residual hip dysplasia (RHD) continues to be a challenging clinical entity. Pelvic radiographs remain the standard in the follow up and evaluation of acetabular development, but can be insufficient to precisely evaluate the entire coverage of the femoral head, when trying to decide on the need for further reconstructive procedures in borderline RHD. We therefore introduced a new ratio comprised of the bony and cartilaginous acetabular angles measured on MRI in order to augment standard radiographs to aid clinicians in deciding if acetabuloplasty is needed. Materiel et methodes We retrospectively compared the bony and the cartilaginous acetabular angles of Hilgenreiner (HTE) in 30 children on pelvic MRI. Twenty children were followed up for DDH. The other 10 children had undergone a pelvic MRI for reasons other than DDH. RHD was defined by a bony HTE superior to 20°. Using standard radiographs, the 60 hips were separated into two groups: group 1 included the hips presenting RHD and group 2 the hips with a HTE below 20°. The hips in the two groups were then compared by introducing a new ratio calculated from the square of cartilaginous HTE above the bony HTE on frontal MRI. The normal upper limit for this acetabular angle ratio (AAR) was set at five and was extrapolated from the published normal values of C-HTE and O-HTE in children. Resultats The AAR was statistically significantly increased in the hips with RHD with a mean value of 7.1 (min.: 1.6, max.: 22.5) compared to the hips in the control group presenting a mean value of 2.1 (min.: 0.1, max.: 8.4) (P Discussion The cartilaginous part of the acetabulum seems to be an early and reliable predictor of acetabular development, as it's fully formed at birth and it is supposed to represent the bony margins of the acetabulum at adulthood after full ossification. The average C-HTE and O-HTE angles from the 27 healthy hips in group 2 corroborated with previous researches. An AAR above five means that not only the bony acetabular coverage is insufficient but also the cartilaginous part and therefore the hips have lower chance to normalize with growth. Moreover, an AAR from below five, even if RHD is seen on plain radiographs, indicates a sufficient cartilaginous coverage with an O-HTE that will correct with growth and we therefore renounce to perform an acetabuloplasty. Conclusion We recommend a pelvic MRI in children presenting borderline residual hip dysplasia on a plain radiography at the age of four and to perform acetabuloplasty if the AAR is superior to five.

The osteoporosis of the child and the teenager is a pathological reality; its multifactorial pathogenesis often requires a collaborative approach and multidisciplinary. The osteoporosis characterized by a reduction in the bone mineral density is not a uniform pathology; it must be dealt with on all the levels by analyzing the factors of risks, by giving itself the diagnostic means and while insisting on the importance of a preventive approach as well as therapeutic.

The aim of this study was to compare clinical and radiological outcome of lateral condyle fracture of the elbow in children treated with bioabsorbable or metallic material. From January 2008 to December 2009, 16 children with similar fractures and ages were grouped according to the fixation material used. Children were seen at 3, 6, and 12 months and more than 4 years (mean 51.8 months) postoperatively. The clinical results were compared using theMayo Elbow Performance Score(MEPS). Radiographic studies of the fractured and opposite elbow were assessed at last follow-up control. Twelve children had a sufficient followup and could be included in the study. Seven could be included in the traditional group and 5 in the bioabsorbable group. At 12 months, the MEPS was 100 for every child in both groups. Asymptomatic bony radiolucent visible tracks and heterotopic ossifications were noted in both groups. There were no significant differences in terms of clinical and radiological outcome between the two groups. The use of bioabsorbable pins or screws is a reasonable alternative to the traditional use of metallic materials for the treatment of lateral condyle fracture of the elbow in children.

Assessing the physical capacity of OI patients is important to evaluate disease progression and to adapt treatment, specifically rehabilitation protocol. While functional scores, such as the medical outcome study short form-36 (MOS SF-36) or the Oswestry disability index (ODI), are validated and used to assess physical capacity in this population, instrumented gait test could improve the evaluation. Analyzing ground reaction forces (GRF) during walking, which can be done with a single force plate, was shown to be an easy and efficient method to differentiate ambulatory pattern in relation to disease severity for a variety of musculoskeletal pathologies. This study tested the hypothesis that OI patients walk with smaller magnitude of vertical and fore-aft forces than control subjects. Gait analysis was performed for 6 OI patients (2 males; 27 ± 9 years old; 26 ± 3 kg m 2 ) and 12 healthy subjects (7 males; 24 ± 2 years old; 22 ± 2 kg/m 2 ). Each study participant walked several trials at self-selected normal speed in a lab equipped with floor-mounted forceplates (Kistler, CH). One leg was randomly selected for analysis and standard characteristic peaks in vertical and fore-aft GRF were measured for each step of the selected leg on a forceplate. To allow comparison among participants, GRF were normalized to percent bodyweight (%BW). Measurements were averaged across trials in order to have one value per GRF peak and participant. Finally, two tailed unpaired t-tests were done to compare GRF peaks between both groups at an alpha level of 5%. OI patients walked with significantly reduced vertical GRF during loading response (88 ± 19 Vs 114 ± 8%BW; P P P = 0.03) and reduced fore force during terminal stance (17 ± 3 Vs 22 ± 4%BW; P = 0.01). OI patients walked slower than controls (1.22 ± 0.14 Vs 1.47 ± 0.20 m/s; P = 0.02). This study showed a significantly lower GRF in OI patients. Smaller GRF were specifically hypothesized in this study due to muscle weakness, proprioceptive acuity diminution and fear of falling in this population. These expected results suggest that a single force plate can already provide valuable information to characterize the ambulatory function of OI patients. The case control comparison yielded results, which were congruent with gait alterations, previously reported in OI and hyperlaxity patients. Further study is needed to evaluate specific change in GFR among OI patients with functional treatment.

Epiphyseal fractures of the distal humerus and their treatment are common, source of many complications that may be immediate but also delayed. If the families accept the possibility of trauma to their child as part of his leisure activities or sports at times intense, they are much more intolerant if their child does not return after injury and repair, optimal function and physical performance unchanged. This intolerance, faced with the trauma but not its consequences, requires us to be particularly careful in the information given to the patient but also in monitoring the first few weeks. The treatment of epiphyseal fractures remains difficult and must be performed by trained teams, aware of the subtleties of pathology. It is essential to organize close monitoring and critical to be able to correct errors or secondary displacement in the first 15 days.

Objective: The aim of this study was to describe sleep quality and associated daytime consequences in idiopathic pulmonary fibrosis (IPF). Subjects and Methods: Fifteen patients with IPF and 15 control subjects matched on age and anthropometric variables were included in the study. Sleep quality and its daytime consequences were assessed by clinical interview, the Pittsburgh Sleep Quality Index (PSQI), the Functional Outcomes in Sleep Questionnaire (FOSQ), the Fatigue Severity Scale (FSS), the Epworth Sleepiness Scale and attended all-night polysomnography. Results: Polysomnography revealed a decrease in sleep efficiency and slow wave sleep, and an increase in stage 1 sleep and arousal index in IPF patients compared to controls. Daytime tachypnea persisted during sleep. Oxygen saturation below 90% was observed during 34.3 ± 37.3% of the total sleep time (TST). Quality of sleep and daytime function were moderately to significantly impaired based on the PSQI and FOSQ. The total FOSQ score was negatively correlated with TST with oxygen saturation below 90% (p = 0.01, r = –0.62). FSS scores were correlated with TST at oxygen saturation below 90% and mean oxygen saturation during sleep (p = 0.002, r = 0.74, and p = 0.007, r = –0.66, respectively). Conclusions: Our data suggest significant sleep disruption and consequent impairment of physical and social functioning in patients with IPF. In the absence of effective treatments for IPF, the improvement of sleep quality should be a primary therapeutic goal.

Fractures of the distal tibial and fibular physes account for 25% to 38% of all physeal fractures1. The juvenile Tillaux fracture corresponds to a Salter-Harris type-3 injury involving the anterolateral distal tibial epiphysis. This intra-articular fracture, which typically occurs in young teenagers as they approach skeletal maturity, is described as a transitional injury because it happens only with a partially fused distal tibial physis. The incidence varies from 2.9% to 5.2% of physeal injuries1,2, and from 3% to 5% of all ankle fractures3. The Tillaux fracture’s pattern, mechanism, and management are well described4,5. The typical mechanism of injury is inversion with external rotation, leading to avulsion of the portion of the lateral tibial epiphysis that is attached to the anterior tibiofibular ligament. The physis underlying the uninvolved medial part of the epiphysis is closed. Treatment recommendations for this injury are based on the extent of displacement of the fragment. Nondisplaced or slightly displaced fractures can be treated conservatively, whereas displacement of more than 2 mm requires closed or open reduction to restore articular congruity1,4. Typically, the Tillaux fragment displaces laterally or anterolaterally3. Steinlauf et al. reported a study that mentions entrapment of the Tillaux fragment between the tibia and fibula, simulating a syndesmosis separation6. To our knowledge, there are no prior published reports of posterior displacement of the fragment. We report a case of a posteriorly displaced Tillaux fragment with an associated fracture of the distal part of the fibula. The latter injury may have permitted the posterior displacement of the Tillaux fragment. The purpose of this report is to create awareness of this unusual injury …