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Resumen Las anomalias ortopedicas del recien nacido son numerosas y no todas pueden ser conocidas por el pediatra. Sin embargo, la exploracion fisica debe ser rigurosa y logica para no olvidar algunas partes de esta. La exploracion debe comenzar por la columna vertebral, seguida de los miembros superiores, antes de centrarse en los miembros inferiores. Las cuatro patologias mas frecuentes en el periodo neonatal son el torticolis congenito, la paralisis obstetrica del plexo braquial, la luxacion congenita de cadera y las deformidades del pie. Las condiciones de la exploracion fisica son esenciales para poder realizar la deteccion en buenas condiciones, por lo que a menudo es necesario repetirla no solo durante la estancia en la sala de maternidad, sino tambien durante las primeras semanas de vida. La solicitud de pruebas complementarias casi nunca es necesaria durante la estancia en la maternidad, pero puede serlo rapidamente en caso de luxacion congenita de cadera. El papel del pediatra no es tanto el de dirigir el proceso terapeutico, que es mas bien responsabilidad del ortopedista pediatrico, sino, una vez que se ha hecho el diagnostico, encontrar las palabras adecuadas para dirigirse a las familias a fin de no preocuparlas o tranquilizarlas equivocadamente

International audience; IntroductionStanding radiographs allow analysis of spinal segments and their relative positioning. However, it requires a specific positioning influencing spinal alignment. Knowledge of trunk movements when walking is therefore an essential step to evaluate dynamic sagittal balance. Our objective was to define spinal junction kinematics and their correlations during gait in a healthy population.MethodThis is a prospective, single-center study. Between 2015 and 2017, 25 healthy volunteers were included. The measurements were taken in a motion analysis laboratory. Several kinematic parameters were studied, including spinal junction movements in the three planes and dynamic sagittal vertical axis (Dyn-SVA). Pearson correlation coefficients were calculated to determine the interactions between the spinal junctions.ResultsIn the sagittal plane, the average amplitude of variation of the dyn-SVA was 25.5 cm (SD = 8.9). The average range of motion of the lumbosacral and thoracolumbar junction was approximately 3°, they operated in anti-phase during the gait cycle and were strongly correlated (r = −0.5069, p = 0.01). In the transverse plane, the anti-rotation of the upper body relative to the pelvis was mainly ensured by the opposite movements of the lumbosacral and thoracolumbar junction (r = 0.5689, p = 0.003). In the frontal plane, the lateral inclination in the lumbar region was made in the opposite direction from the pelvis toward the carrying member.ConclusionAlthough there is substantial inter-subject variability, our study characterized the angular movements in the three planes of the different spinal junctions, of the pelvis and the lower limbs during a gait cycle in a healthy population.

La traumatologia pediatrica e un’area particolarmente delicata in termini di diagnosi. Se la presentazione clinica non e molto diversa da quella dell’adulto, l’interpretazione dei dati della diagnostica per immagini puo rivelarsi delicata a causa della matrice cartilaginea molto importante nel bambino. Cio e particolarmente vero per il gomito, regione anatomica in cui sono presenti molti nuclei di ossificazione epifisari. Il buon supporto diagnostico di queste lesioni impone al professionista una conoscenza precisa dell’evoluzione dello scheletro in accrescimento. La gestione iniziale deve comportare una contenzione e un’analgesia efficaci. La gestione terapeutica e molto consensuale su queste grandi linee. A causa dell’elevato potenziale di rimodellamento nei bambini, una gran parte e lasciata al trattamento ortopedico. I limiti della correzione spontanea dei difetti residui devono essere noti fin dalla fase iniziale, per evitare modificazioni secondarie della strategia, fonti di perdita di tempo e di fiducia da parte della famiglia. Le principali urgenze sono il trauma vascolare dell’arteria omerale al gomito e poplitea al ginocchio. Esse possono passare inosservate a causa della ricchezza della rete collaterale del bambino. Queste complicanze devono essere sistematicamente ricercate in caso di frattura sovracondilica del gomito e di frattura femorale distale.

Resume Introduction Le transfert libre de fibula vascularisee est largement utilise dans les pertes de substance osseuse malgre l’utilisation d’un site donneur sain. Notre hypothese etait que la stabilisation de la fibula distale par une baguette tibiale diminue la prevalence du valgus de cheville. L’objectif de ce travail etait d’analyser la morbidite clinique et les modifications radiologiques du site donneur chez l’enfant. Materiel et methode Ont ete inclus 31 enfants provenant de deux centres entre 1994 et 2014. L’âge moyen etait de 8,9 ans (2–14), le recul moyen de 6,6 ans (2–21). Les parametres evalues etaient la survenue des complications precoces et tardives. Resultats Dix-sept complications precoces ont ete retrouvees, dont 82,4 % ont regresse sans sequelle en 7 mois. Six valgus de cheville ont ete recenses (19,4 %). L’index fibulaire distal residuel inferieur a 16 n’etait pas statistiquement associe a un risque de valgus, bien que tres proche de la significativite (p Discussion La morbidite clinique du site donneur lors des prelevements de lambeau libre de fibula etait non negligeable mais rapidement regressive. Un index fibulaire residuel distal inferieur a 16 n’etait pas a lui seul predictif de valgus. Nous recommandons une vis de syndesmodese tibio-fibulaire distale quadri-corticale ou l’association vis-baguette tibiale pour prevenir le valgus de cheville, la baguette tibiale isolee etant grevee d’un taux important de deformation. Niveau de preuve IV.

Resume Introduction Les modalites d’osteosynthese des fractures supracondyliennes du coude de l’enfant restent controversees. L’objectif de cette etude etait de comparer les resultats de 5 types d’osteosynthese dans le traitement des fractures supracondyliennes du coude (FSC) de l’enfant. Hypothese Il est possible de mettre en evidence des differences sur les parametres peroperatoires et a court terme entre les differents types d’osteosynthese dans les FSC. Patients et methodes De 2006 a 2016, les dossiers de patients pediatriques admis dans notre institution pour FSC type 3–4 (Lagrange-Rigault) ont ete revus. Differents parametres radiocliniques ont ete collectes en postoperatoire et au dernier recul, comme l’angle de Baumann, l’anteversion de l’epiphyse humerale distale et le temps operatoire. Sur une periode de 10 ans, 251 patients ont ete inclus (âge 6,4 ans, recul 4,7 mois). Les differents types d’osteosynthese etaient : ECMES (n = 16), 2 broches en croix (n = 33), 2 broches laterales et 1 mediale (n = 144), 2 broches laterales (n = 33) et 3 broches laterales (n = 25). Un mini-abord (2 cm) etait realise pour l’insertion de la broche mediale. Une instabilite immediate de l’osteosynthese etait consideree lorsqu’il existait un deficit de l’angle de Baumann ou de l’anteversion de plus de 15° ou un trouble de rotation sur la radiographie a j1. Les resultats etaient analyses en fonction du type d’osteosynthese realisee. Resultats Il n’y avait pas de difference en termes d’instabilite immediate entre les differents types d’osteosynthese. L’osteosynthese par 2 broches laterales necessitait un temps operatoire plus court (33 min, p = 0,046). Les patients ayant eu un ECMES avaient un delai d’ablation du materiel plus long (54j, p = 0,03). L’insertion d’une broche mediale etait associee a un taux de deplacement secondaire plus faible (2 % vs 8,6 %, p = 0,04) avec un taux de complication neurologique identique (3,4 % vs 3,4 %, p = 0,98). Discussion Cette etude est l’une des plus importantes rapportant les resultats du traitement des FSC selon differentes osteosyntheses sous la forme d’une etude de cohorte retrospective. Bien que necessitant un temps operatoire plus long, l’ajout d’une broche mediale par un mini-abord permet de limiter les deplacements secondaires sans augmenter le risque de lesions neurologiques iatrogenes et permet d’obtenir une meilleure stabilisation du foyer de fracture. Elle devrait donc etre consideree lors du traitement chirurgical des FSC de l’enfant. Niveau de preuve IV, etude de cohorte retrospective.

Resume Introduction Les atteintes medullaires iatrogenes sont les complications les plus redoutees des chirurgies de deviation vertebrale. Le monitoring neurophysiologique peroperatoire permet de tester en temps reel les fonctions medullaires et ainsi de diminuer l’incidence de ces complications. Hypothese En cas d’alerte severe du monitoring, la determination neurophysiologique peroperatoire d’un niveau lesionnel constitue une information supplementaire et utile. Materiel et methode Cette etude est retrospective et monocentrique. Au total, 1062 chirurgies de deviation vertebrale ont ete monitorees dans notre centre depuis 2004. Six alertes severes du monitoring avec determination neurophysiologique du niveau lesionnel sont survenues. Le monitoring a ete realise avec des potentiels evoques somesthesiques (PES), des potentiels evoques mixtes neurogeniques (PEMN) et des ondes D. Le deplacement sequentiel d’une electrode spinale epidurale permet la determination d’un niveau lesionnel, en utilisant cette electrode soit pour la stimulation soit pour l’enregistrement. Resultats Six patients (12–17 ans), ayant presente une alerte severe du monitoring peroperatoire avec determination du niveau lesionnel sont rapportes. L’examen neurologique postoperatoire etait normal pour 5 des 6 patients. Pour la patiente 2, la determination du niveau lesionnel identifiait une pince bi-lamaire positionnee en T2-T3 comme etiologie de l’alerte. Cette alerte etait retardee, etant detectable seulement 30 minutes apres la pose de la pince bi-lamaire. L’examen neurologique postoperatoire etait normal. Le patient 6 etait paraplegique au test de reveil peroperatoire. Apres des manœuvres de correction guidees par le niveau lesionnel T6, le deficit neurologique postoperatoire etait limite a un syndrome pyramidal d’un membre inferieur. L’IRM mettait en evidence un hypersignal medullaire correspondant au niveau lesionnel peroperatoire. Discussion De rares donnees d’alertes severes du monitoring medullaire sont decrites. La determination d’un niveau lesionnel, possible quel que soit le dispositif de monitoring utilise, permet de rapidement determiner la cause de l’alerte, permettant alors a l’equipe chirurgicale de reagir de la facon la plus appropriee. Type d’etude Retrospective. Niveau d’evidence scientifique IV.

Background In spinal deformity surgery, iatrogenic spinal cord injury is the most feared complication. Intraoperative monitoring (IOM) of the spinal cord assesses its functional integrity and allows significant reduction of the rate of spinal cord injury. Hypothesis In case of severe IOM alert, lesional level diagnosis constitutes supplementary and useful information. Material and methods This study was retrospective and monocentric. In our institution, 1062 pediatric spinal deformity surgeries have been monitored since 2004. We review the records of the six patients who presented a severe and prolonged IOM alert with lesional level determination. Somatosensory evoked potentials (SSEP), neurogenic mixed evoked potentials (NMEP) and D-waves were performed. In cases of IOM alert, sequentially moving an epidural electrode along the spinal cord allows lesional level determination, using this electrode either for stimulation or recording. Results Six patients, aged 12 to 17 years, characterized by severe IOM alerts during spinal deformity surgery are reported. Postoperative neurological examination was normal for five out of six cases. For patient 2, lesional level diagnosis allowed to determine a bi-laminar claw between T2 and T3 as the etiology of IOM alert. This IOM alert was delayed in time, being detectable only 30 minutes after the placement of this claw. Postoperative neurological examination was normal. For patient 6, a Stagnara wake-up test demonstrated paraplegia. Lesional level was established. Following corrective surgical maneuvers, postoperative neurologic deficit was limited to a pyramidal syndrome in one lower limb. Postoperative MRI demonstrated a spinal cord lesion at the determined lesional level. Conclusion During an IOM alert, lesional level determination allows localization of spinal cord dysfunction. This data, obtainable whatever the IOM device, constitutes supplementary information in order to rapidly identify the etiology of IOM alert and thus to react in the most appropriate way. Level of evidence IV, retrospective study.

In adolescent idiopathic scoliosis (AIS), spinal deformity can be seen in the thoracic or in the lumbar area. Although differences according to curve location are well described on standard radiographs, dynamic consequences of such difference remain unclear. Our objective was to explore the differences in dynamic spinal balance according to curve location in AIS patients using gait analysis METHODS: We prospectively included 22 females with AIS planned for surgical correction (16.3 years old, 81% Risser ≥ 4). Patients were divided into two matched cohorts, according to major curve location [right thoracic (Lenke 1) or left lumbar (Lenke 5)]. Gait analysis was performed the day before surgery. Global balance was analyzed as the primary outcome. Local curves parameters (dynamic Cobb angles) were defined as the secondary outcome.In coronal plane, Lenke 5 patients had a left trunk shift, whereas trunk was shifted to the right in Lenke 1 patients (- 20.7 vs 6.3, p = 0.001). In the sagittal plane, the main difference between the two groups was T12 position that remained over the pelvis during gait in Lenke 5 patients, whereas it was anterior to the pelvis in Lenke 1 patients. In the transversal plane, Lenke 5 and Lenke 1 patients presented the same gait abnormalities, with a global trunk rotation to the left (- 4.8 vs - 7.6, p = 0,165).This is the first study to provide the results of a direct comparison between Lenke 1 and Lenke 5 patients during gait. Curve location influenced coronal and sagittal balance, but abnormalities of transversal trunk motion were the same, wherever the curve was located. These slides can be retrieved under Electronic Supplementary Material.

Spinal muscular atrophies (SMA type 1, 2, 3) present with various severities according to the motor semeiology related to lesions of the peripheral nervous system (lesions of the anterior horn cells motoneuron or even brain stem). Early motor deficiency causes skeletal deformities responsible for the alteration or even absence of motor skills acquisition. The management of these patients involves several practitioners: pediatric neurologist, pediatric pneumologist, physical medicine and rehabilitation therapist, pediatric orthopedic surgeon, psychologist, physiotherapist, etc. Therefore, this multidisciplinary management must take place in a reference center. This has allowed for improvement of the natural history of SMA. Despite the severity of clinical presentation, especially in SMA type 1 or 2, the functional aspect is always to be taken into account in the first instance. Furthermore, the natural history of the disease is currently being modified by the emergence of innovative therapies that will change the evolution of the disease and its management. Indeed, current treatment objectives are the comfort of installation and the fight against neuro-orthopedic degradation. Although the rise in the number of innovative therapies has led to increased expectancies, such as motor function improvement, practitioners should be aware that these innovative treatments should be balanced against child development and the disease's natural history. Scoliosis surgery is almost systematic in SMA type 2 because of trunk muscular deficiency, especially intercostal muscle insufficiency, and spino-pelvic complex disorder. However, surgical techniques have evolved to become less invasive and more growth friendly in order to follow child development. The final goal of surgery in SMA patients is to obtain a 3-dimensional deformity correction along with a spino-pelvic realignment in order to allow for a comfortable seated position, which is the position of function in these patients, and to allow for better ventilation. Faced with this global approach and innovative therapies, global assessment is warranted not solely in an isolated manner, as is usually the case during hospital stays with traditional scales, but rather during daily activities. This is the case of daily monitoring, which allows for motor skill and activity assessments throughout the day. The principle is to characterize, according to SMA type and treatment, the activity type (standing, seated, walking), duration, intensity and frequency. The ultimate goal would be to identify the variety and occurrence of motor activities, and finally to clarify if the different treatments, including innovative therapies, lead to functional improvement in these patients. © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.

The treatment objectives in congenital pseudarthrosis of the tibia are bone consolidation and a restored lower-limb axis. They are difficult to achieve, and various surgical techniques have been described, with varying results in terms of bone consolidation and complications. The present study reports clinical and radiographic results in 3 patients managed by the same original technique of transplantar intramedullary nailing using a custom-made proximal locking nail, without surgical approach or resection of the pseudarthrosis site. Good assembly stability allowed immediate weight-bearing. The technique is relatively noninvasive, offering a first-line alternative in under-3 year-olds.

Resume L’objectif du traitement de la pseudarthrose congenitale est l’obtention d’une consolidation osseuse associee a la restitution de l’axe du membre inferieur. Ces objectifs sont difficiles a obtenir et de nombreuses techniques chirurgicales ont ete decrites offrant des resultats heterogenes en termes de consolidation osseuse et de survenue de complications. Le but de ce travail est de presenter les resultats cliniques et radiographiques de trois patients pris en charge selon une technique originale d’enclouage centromedullaire par voie transplantaire utilisant un clou sur mesure a verrouillage proximal sans abord ni resection du foyer de pseudarthrose. La bonne stabilite du montage autorise un appui immediat. Il s’agit d’une technique peu invasive constituant une approche chirurgicale supplementaire de premiere intention chez l’enfant de moins de 3 ans.

In the last few years several reports stressed the importance of sagittal alignment in adolescent idiopathic scoliosis (AIS) patients. It was recently reported that T1 slope, defined as the angle between the superior endplate of T1 and the horizontal, correlates strongly with overall sagittal parameters. The aim of this study was to assess the impact of T1 parameters (T1-slope and T1-tilt) on sagittal alignment of AIS hypokyphotic patients preoperatively and postoperatively. Twenty-nine AIS patients with

Las deformaciones principales de la pared anterior del torax son el pectus excavatum y el pectus carinatum. Las formas aisladas sin repercusion funcional grave son las mas frecuentes. La causa sugerida en la mayoria de los casos es una displasia de los cartilagos costales asociada a un desequilibrio de su crecimiento. Se pueden plantear tres principios terapeuticos. El primero tiene un planteamiento radical. Se trata de la reseccion de los cartilagos costales anormales o esternocondroplastias. La tecnica de condroplastia subpericondrica por una via de acceso horizontal minimamente invasivo permite tratar las formas complejas en pacientes adultos, y en menos ocasiones en la infancia. A esta tecnica se le asocia, en los casos de pectus excavatum, la colocacion de una ferula metalica retroesternal durante 6 meses. Las indicaciones de osteotomias esternales son actualmente infrecuentes. El segundo principio se basa en el modelado progresivo del torax durante el periodo de crecimiento toracico. La correccion se realiza con una placa de osteosintesis, que actua como un autentico tutor esternocostal temporal. Se puede introducir por una via minimamente invasiva con control toracoscopico. Esta tecnica es exclusiva del pectus excavatum simetrico en adolescentes. En las formas particularmente graves, un acceso subxifoideo minimo permite elevar el esternon y asegurar el paso de la placa. Se han descrito tecnicas recientes, como las campanas de succion, con resultados considerados prometedores, pero que no se han demostrado por el momento. En el pectus carinatum, una compresion externa mediante una ortesis proporciona buenos resultados demostrados. El tercer principio terapeutico es un tratamiento paliativo dirigido al relleno de la excavacion con una protesis de silicona. Su interes es la sencillez inmediata. Presenta el inconveniente de los riesgos de complicacion y de migracion del implante de silicona que se mantiene colocado varias decadas. En resumen, las indicaciones terapeuticas pueden decantarse por tecnicas quirurgicas diferentes, pero complementarias.

Resume Introduction A ce jour, il n’existe pas de solution therapeutique consensuelle pour les scolioses idiopathiques de l’adolescent (SIA) dont la courbure est comprise entre 30 et 60° en fin de croissance. Objectif L’objectif de cette etude etait d’effectuer une evaluation du devenir a long terme des patients porteurs d’une SIA d’amplitude moderee. Materiel et methodes Il s’agit d’une etude retrospective multicentrique. Les criteres d’inclusion etaient un angle de Cobb en fin de croissance compris entre 30 et 60° et un recul superieur a 20 ans. Les donnees recueillies etaient les valeurs angulaires a l’adolescence et au dernier recul et des scores de qualite de vie au dernier recul. Resultats Au total, 258 patients ont ete inclus, dont 100 patients operes a l’adolescence, 116 n’ayant jamais ete operes et 42 operes a l’âge adulte. Le recul moyen etait de 27,8 ans. L’augmentation de l’angle de Cobb au recul etait significativement differente dans les 3 groupes (respectivement 3,2° vs 8,8° vs 23,6°, p p = 0,002). Les scores de qualite de vie ne montraient pas de difference significative. Discussion Les patients operes a l’adolescence avaient une faible progression radiologique, demontrant l’efficacite du traitement chirurgical pour des courbures superieures a 50°. Les courbures superieures a 40° sont evolutives et necessitent parfois un traitement chirurgical a l’âge adulte. Les scolioses lombaires ont montre un potentiel evolutif plus important que les scolioses thoraciques a l’âge adulte et justifient une arthrodese des que l’angulation atteint 35°. Niveau de preuve 4.

IntroductionTo date there is no consensus on therapeutic indications in adolescent idiopathic scoliosis (AIS) with curvature between 30° and 60° at the end of growth.ObjectiveThe objective of this study was to assess outcome in patients with moderate AIS.Material and methodsA multicenter retrospective study was conducted. Inclusion criteria were: Cobb angle, 30–60° at end of growth; and follow-up > 20 years. The data collected were angular values in adolescence and at last follow-up, and quality of life scores at follow-up.ResultsA total of 258 patients were enrolled: 100 operated on in adolescence, 116 never operated on, and 42 operated on in adulthood. Mean follow-up was 27.8 years. Cobb angle progression significantly differed between the 3 groups: 3.2° versus 8.8° versus 23.6°, respectively; P 35° (OR=4.278, P=0.002). There were no significant differences in quality of life scores.DiscussionPatients operated on in adolescence showed little radiological progression, demonstrating the efficacy of surgical treatment for curvature greater than 50°. Curvature greater than 40° was progressive and may require surgery in adulthood. Lumbar scoliosis showed greater potential progression than thoracic scoliosis in adulthood, requiring fusion as of 35° angulation.Level of evidenceIV, retrospective study.

Mild head trauma can be associated with concussion, defined as transient brain function impairment without radiological findings. Sports-related concussion is also reported in pediatrics (rugby, ice hockey, football, boxing, etc.). Misdiagnosis can lead to persistent neurocognitive signs with athletic and academic problems. Consensual tools are available, but they are not well-known by first-line doctors, coaches, and patients or parents. Concussed players should not be allowed to return to the field on the same day. Return to play should be gradual over 3weeks or more. School activities may need to be modified to favor cognitive rest. Prevention is based on risk information and knowledge transfer, rule changes, and protective helmets, whose effectiveness is not always proven.

The best method for stabilising supracondylar humeral fractures (SHFs) in children remains unclear. The objective of this study was to compare the outcomes of five different fixation methods for SHFs in children.Differences in intra-operative and short-term post-operative parameters can be demonstrated across different fixation methods for SHFs in children.We reviewed the medical files of paediatric patients managed at our centre between 2006 and 2016 for SHF with major displacement (type 3 or 4 in the Lagrange-Rigault classification). Clinical and radiological parameters collected post-operatively and at last follow-up included Baumann's angle, anteversion of the distal humeral epiphysis, and operative time. Over the 11-year study period, 251 patients were included; mean age was 6.4 years and mean follow-up 4.7 months. The five fixation methods used were elastic stable intra-medullary nailing (ESIN, n=16), two pins in an X configuration (n=33), two lateral pins and one medial pin (n=144), two lateral pins (n=33), and three lateral pins (n=25). A minimally invasive 2-cm approach was used to insert the medial pins. Immediate instability of the fixation was considered in patients with an at least 15° deficit in Baumann's angle or anteversion, or with rotational malalignment, on the radiographs taken on day 1. Outcomes were analysed in each of the five internal fixation groups.Immediate instability showed no significant differences across the five groups. Operative time was significantly shorter with two lateral pins (33min, P=0.046). Time to hardware removal was longer in the ESIN group (54 days, P=0.03). Use of a medial pin was associated with a lower risk of secondary displacement (2.0% vs. 8.6%, P=0.04) but did not affect the risk of nerve injury (4% vs. 3%, P=0.86).This is one of the largest retrospective cohort studies of outcomes according to the fixation technique used to treat SHFs in children. Adding a medial pin through a minimally invasive approach is associated with a longer operative time but limits the risk of secondary displacement without increasing the frequency of iatrogenic nerve injury and improves fracture site stability. Use of a medial pin therefore deserves to be considered in paediatric SHFs.IV, retrospective cohort study.

International audience; Pediatric orthopedic surgery in humanitarian aid is conducted mainly in cooperation with emerging countries. Each mission is different, and depends on numerous parameters such as the country, the frequency of such missions, the pathologies encountered, the local structure and team, and the non-governmental organization (NGO) involved. Pathologies vary in etiology (tuberculosis, poliomyelitis) and severity. Each mission requires the presence of an experienced surgeon. Working conditions are often rudimentary. Surgical indications should be restricted to procedures that are going to be effective, with minimal postoperative complications, without any surgical "acrobatics". Teaching should be in association with the local university, and adapted to local needs. Mission objectives need to be realistic. Surgical indications should be adapted to local conditions, and the surgeon needs to be able to say "no" to procedures involving undue risk. The surgeon on mission should cooperate with local teams and be able to adapt to unusual situations. Assessment of results is essential to improving efficacy and evaluating the success of the mission.

Resume Introduction Le but de notre etude etait d’analyser les resultats a moyen et long termes de l’osteotomie de l’extremite proximale de l’ulna avec et sans ligamentoplastie dans les lesions de Monteggia vieillies chez l’enfant. Materiel et methodes Dans cette etude retrospective, multicentrique de 28 patients, les criteres cliniques concernaient la mobilite, la douleur, et le score MEPI ; les criteres radiographiques, la ligne de Storen, le head-neck ratio, l’angulation du col radial, et la recherche de remaniements osteo-arthrosiques. Resultats Vingt-huit patients ont ete revus, avec un recul moyen de 6 ans (2–34 ans). Seize patients ont eu une osteotomie proximale de l’ulna sans ligamentoplastie, 12 patients ont eu une ligamentoplastie. Les deux groupes ont eu une amelioration significative clinique et radiologique. Il n’a pas ete retrouve de difference significative en comparant leurs resultats. Les patients operes dans un delai inferieur a 1 an presentaient de meilleurs resultats cliniques et radiologiques. Il n’existait pas de correlation entre l’âge a l’intervention et la qualite des resultats. Les 5 patients ayant eu une broche trans-condylo-radiale ont eu une recidive precoce de la luxation et des remaniements osteo-arthrosiques. Les trois cas Bado 3 ont eu une recidive precoce de la luxation. Discussion L’intervention de Bouyala donne de bons resultats a long terme, dans les lesions Bado 1, quel que soit l’âge, en cas de prise en charge avant 1 an, en l’absence de remaniement osteo-arthrosique. L’interet de la ligamentoplastie depend de la complication a traiter. Niveau de preuve IV (etude retrospective).

Resume Introduction Le pectus excavatum (PE) est une malformation congenitale frequente. La correction chirurgicale mini-invasive de Nuss (CCMI) consiste a relever par voie endoscopique le sternum par une plaque ou barre retrosternale. A partir d’une serie de 70 enfants, nous proposons d’en preciser les indications, notamment les limites. Materiel et methode Il s’agissait d’une etude retrospective et bicentrique. Soixante-dix enfants operes sont arrives en fin de croissance avec leur plaque retiree. La moyenne d’âge etait de 13,8 ans (6–19 ans). L’indication operatoire etait esthetique dans 66 cas (95 %). Soixante-trois ont ete operes selon la technique originale de Nuss. Sept patients ont necessite une voie d’abord complementaire sous-xiphoidienne. L’ablation de la plaque a ete realisee de 8 mois a 3 ans apres la pose. Resultats Le resultat esthetique a ete juge satisfaisant dans 64 cas (91 %) par les patients et 60 cas (85,7 %) par le chirurgien. Des complications majeures ont ete observees dans 6 cas (8,5 %) ayant necessite une reprise chirurgicale : 2 hemothorax, 2 sepsis parietaux (dont un apres ablation de la plaque), une allergie et une mobilisation de la plaque. Les complications mineures (46 cas [65 %]), precoces ou tardives, ont ete spontanement resolutives ou traitees medicalement. Discussion La faible rancon cicatricielle et la fiabilite du resultat obtenu sont en faveur de la diffusion de la technique de Nuss chez l’enfant et l’adolescent. Nos taux de complications etaient similaires aux donnees de la litterature (65 % mineures, 8,5 % majeures). Nous considerons que les patients presentant des antecedents de chirurgie cardiothoracique ou ceux presentant au scanner une distance sterno-vertebrale inferieure a 5 cm ou une rotation sternale superieure a 35° contre-indiquent une technique par voie endoscopique. Nous recommandons alors un controle sous- et retroxiphoidien ou une sternochondroplastie classique. Niveau de preuve Etude de cohorte descriptive, niveau 4.

Resume Introduction Au cours des allongements de tibia, il est recommande de prevenir la migration proximale de la malleole fibulaire par une vis de syndesmodese tibio-fibulaire distale, qui est retiree a 6 mois. Nous avons constate des migrations proximales de malleole fibulaire malgre cette vis de syndesmodese. Objectif L’objectif de notre etude etait de mettre en evidence cette migration et d’etudier l’influence de 2 facteurs pouvant la favoriser : le positionnement de la vis de syndesmodese et la consolidation de la fibula lors de son ablation. Hypothese Une fibula non consolidee au moment de l’ablation de la vis de syndesmodese tibio-fibulaire distale et son positionnement tri-cortical favorisent la migration proximale de la malleole fibulaire. Materiels et methodes Il s’agissait d’une etude analytique retrospective monocentrique. Etaient inclus 22 programmes d’allongement chez 18 patients de 5 a 17 ans ayant eu un allongement de tibia et presentant une fibula continue preoperatoire. La position de la malleole fibulaire, la consolidation de la fibula, et le positionnement tri-ou quadri-cortical de la vis etaient evalues sur 4 radiographies successives. Resultats Le positionnement tri-cortical de la vis de syndesmodese etait associe significativement a une migration proximale de la malleole fibulaire au cours de l’allongement ( p = 0,0248 p = 0,164 > 0,05). Discussion La migration proximale de la malleole fibulaire au cours de l’allongement est favorisee par une vis de syndesmodese non quadri-corticale. Son positionnement quadri-cortical doit etre recommande. La migration de la malleole fibulaire apres l’ablation de la vis de syndesmodese semble etre en rapport avec une absence de consolidation de la fibula, mais notre serie etait insuffisante pour le mettre en evidence. Niveau de preuve IV Etude retrospective.

Thoracic adolescent idiopathic scoliosis (AIS) curves (Lenke 1–4) are often characterized by hypokyphosis. Sagittal alignment remains challenging to correct, even with recent posterior segmental instrumentation. Some authors recommend anterior endoscopic release (AER) to reduce anterior column height, and facilitate thoracic kyphosis correction. The aim of this study was to assess the contribution of AER to sagittal correction in hypokyphotic AIS. Fifty-six hypokyphotic (T4T12

Las deformidades de la pared toracica aparecen en la mayoria de los casos tras un exceso de crecimiento de los cartilagos costales que desplaza el esternon hacia dentro (pectus excavatum, lo mas frecuente) o, mas raramente, hacia fuera (pectus carinatum). En estos casos, la deformidad aparece y empeora progresivamente durante la infancia, con un pico maximo al inicio de la pubertad. La prescripcion de un tratamiento quirurgico u ortopedico se basa esencialmente en el perjuicio estetico, sobre todo en la adolescencia. Las manifestaciones cardiacas o respiratorias son raras, pero deben buscarse. Otras deformidades, claramente mas raras y a menudo congenitas, forman parte de sindromes complejos de dificil correccion.

Mucopolysaccharidoses (MPS) are a group of disorders characterized by the accumulation of glycosaminoglycans. Skeletal abnormalities are early and prominent features of MPS. Cervical spine and atlantoaxial instability, thoracolumbar kyphosis, hip dysplasia and osteonecrosis, genu valgum, and carpal tunnel syndrome are frequently observed. MPS disease-awareness is important for pediatric healthcare providers who should be able to recognize the clinical presentation, musculoskeletal abnormalities, and radiographic findings associated with this group of disorders.

Objective In hemiplegic children the appearance of equinovarus is correlated with premature electromyography (EMG) activity of the gastrocnemius medialis (GM) prior to initial contact. The goal was to analyze the onset of EMG activation in the GM and, more particularly, the peroneus longus (PL) in cases of equinovarus: is PL activity likewise premature? Material and methods As 15 hemiplegic children (age 5 years ± 1.5) with equinovarus walked, their PL and GM EMG activity was being recorded. The latter was normalized in terms of gait cycle percentage (0–100%) and detected through semi-automatic selection with activation threshold set at 20 μV. A paired t-test compared activation onset of the PL versus the GM muscles. Results As regards the healthy limb, activity onset of the GM (+14.55%) and the PL (+19.2%) muscles occurred only during the ST. In cases of equinovarus, activation of the GM (−5.2%) and the PL (−6.1%) occurred during the SW and was premature. For each muscle, comparison between the healthy and the hemiplegic side was highly significant (P Conclusion Premature PL and GM EMG activity preceding initial contact corresponds not to a disorder secondary to imbalance but rather, more probably, to motor command dysfunction. While the PL consequently contributes to equinus deformity, its possible role in varus genesis is less evident. EMG study needs to be completed by comparing PL and tibialis posterior strength while taking foot bone morphology into full account.

Introduction/Background In very young cerebral palsy (CP) children, peroneus longus (PL) overactivity by spastic co-contraction is a major contributor to dynamic equinovalgus during swing phase (SW) and at initial contact (IC). This study assessed the effects of abobotulinum toxin A injections into PL. Material and method Eleven male children with hemiparesis (7 right; age 3.1 ± 0.6 yo) were injected once in PL, without GastroSoleusComplex (GSC) injection. GSC was assessed for functional length (XV1) and spasticity (XV3). Gait analysis videos were evaluated using the Edinburgh visual gait score (EVGS-validated in CP): pre- vs. post-injection values were compared using paired t-tests. EMG monitored tibialis anterior (TA), gastrocnemius medialis (GM) and PL during gait. Swing phase was divided into three periods (SW1, SW2, SW3) to measured, using EMG: GM and PL co-contractions and TA recruitment during SW (SW, SW1, SW2, SW3), during standing on tiptoes (EMGmaxPL, EMGmaxGM), standing on heels (EMGmaxTA). For each measured EMG variable, efficacy indices was assessed using the ratio (EMGVARIABLE-X_POST − EMGVARIABLE-X_PRE)/(EMGVARIABLE-X_POST + EMGVARIABLE-X_PRE) and compared with an inefficacy theoretical index of 0. Results Comparison involved 1937 pre-toxin strides (mean per child 176 ± 114) vs. 1231 post-toxin strides (mean 112 ± 79). There were no difference in XV1-GSC (XV1-GSC-pre103°[6]; XV1-GSC-post103°[6] or in XV3-GSC (XV3-GSC-pre89°[8]; XV3-GSC-post96°[4.5]). EVGS-global-score was improved (P = 0.007) with better clearance in SW (P = 0.07), increased knee re-extension in terminal SW (P = 0.04) and decreased hindfoot valgus at IC (P = 0.02). The normalised-EMGmax was unchanged for PL (−0.06 [0.16]) but increased for GM (0.18 [0.20], P = 0.007) and TA (0.28 [0.19], P Conclusion In this retrospective study, PL injections in very young CP children improved foot clearance and decreased hindfoot valgus, which was associated with reductions of PL and GM co-contractions and of TA recruitment. This constitutes an argument supporting that increased TA recruitment in children with hemiparesis may be an attempt by the nervous system to compensate for plantar flexor co-contraction rather than the opposite (increased co-contraction due to increased TA recruitment). We can discuss a central action of abobotulinum toxin A.

Resume Le monitoring medullaire peroperatoire consiste en une evaluation sub-continue des fonctions sensitivomotrices medullaires et permet de reduire l’incidence des complications neurologiques des chirurgies du rachis. Une association de techniques est utilisee : potentiels evoques somesthesiques (PES), potentiels evoques moteurs (PEM), potentiels evoques mixtes neurogeniques (PEMN), ondes D et testing des vis pediculaires. En l’absence de neurophysiologie peroperatoire, le test de reveil peroperatoire constitue une reelle forme de monitoring meme si sa latence est importante et sa precision aleatoire. Une enquete en 2011 aupres de 117 chirurgiens francais revele que seulement 36 % disposent d’un monitoring neurophysiologique (structures publiques : 42 % et privees : 27 %). Le monitoring peut etre realise par un neurophysiologiste en salle d’operation, a distance en utilisant un reseau informatique ou encore par le chirurgien lui-meme. Les alertes peroperatoires permettent le diagnostic en temps reel d’une souffrance medullaire. L’utilisation d’electrodes spinales deplacees le long du canal medullaire permet de determiner le niveau lesionnel (PEMN, ondes D). Les alertes sont a interpreter en fonction des phases operatoires et ne conduisent pas systematiquement a un arret de l’intervention. Un monitoring multimodalitaire, en presence d’un neurophysiologiste, en collaboration avec l’anesthesiste, est la technique la plus fiable. Cependant, aucune technique de monitoring ne peut predire une paraplegie qui debutera de facon differee, quelques heures apres la fin de la chirurgie. En cas de deficit neurologique preexistant, le monitoring est peu contributif. Le monitoring des racines L1 a L5 est egalement peu fiable. Ainsi le monitoring n’a pas d’indication en chirurgie discale et degenerative du rachis lombaire. Cependant, le testing des vis pediculaires peut representer un apport interessant. Au total, les deviations vertebrales thoraciques et thoracolombaires sans trouble neurologique sont actuellement l’indication essentielle du monitoring medullaire. Son absence dans cette indication represente une perte de chance pour le patient. En cas de non-disponibilite des moyens neurophysiologiques, le reveil peroperatoire constitue alors une obligation minimale de moyens.

SummaryIntraoperative spinal cord monitoring consists in a subcontinuous evaluation of spinal cord sensory-motor functions and allows the reduction the incidence of neurological complications resulting from spinal surgery. A combination of techniques is used: somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), neurogenic motor evoked potentials (NMEP), D waves, and pedicular screw testing. In absence of intraoperative neurophysiological testing, the intraoperative wake-up test is a true form of monitoring even if its latency long and its precision variable. A 2011 survey of 117 French spinal surgeons showed that only 36% had neurophysiological monitoring available (public healthcare facilities, 42%; private facilities, 27%). Monitoring can be performed by a neurophysiologist in the operating room, remotely using a network, or directly by the surgeon. Intraoperative alerts allow real-time diagnosis of impending neurological injury. Use of spinal electrodes, moved along the medullary canal, can determine the lesion level (NMEP, D waves). The response to a monitoring alert should take into account the phase of the surgical intervention and does not systematically lead to interruption of the intervention. Multimodal intraoperative monitoring, in presence of a neurophysiologist, in collaboration with the anesthesiologist, is the most reliable technique available. However, no monitoring technique can predict a delayed-onset paraplegia that appears after the end of surgery. In cases of preexisting neurological deficit, monitoring contributes little. Monitoring of the L1–L4 spinal roots also shows low reliability. Therefore, monitoring has no indication in discal and degenerative surgery of the spinal surgery. However, testing pedicular screws can be useful. All in all, thoracic and thoracolumbar vertebral deviations, with normal preoperative neurological examination are currently the essential indication for spinal cord monitoring. Its absence in this indication is a lost opportunity for the patient. If neurophysiological means are not available, intraoperative wake-up test is a minimal obligation.

Adolescents who attempt suicide are a major concern. A growing body of literature seeks to explain this phenomenon and to identify its predictive factors, but relatively little information is available and children and adolescents under 15 years of age who present to general hospitals because of a suicide attempt. This study aimed to describe the demographic, social, medical, and psychological characteristics of a large sample of 517 French adolescents aged not more than 15 years 3 months. A second purpose was to measure observance of psychological care in a 1-year follow-up. Third, we aimed to document the reattempt rate during the follow-up in this population of young adolescents. Following the French official recommendations, a systematic 72-h hospitalization as well as a somatic, social, and psychological assessment was proposed to every suicide attempter after his or her admission to the emergency department. The adolescent was followed for 1 year after the suicide attempt, called the index episode. This follow-up was organized by two physicians, one of whom was not associated with the care of any of the patients. It consisted in seeking regular information as well as organization and/or optimization of the patient's psychological care, which was delivered in dedicated structures for adolescents, in outpatient care by a psychiatrist, or in an adolescent psychiatric inpatient care unit. In case of a repeated suicide attempt or persistence of alarming symptoms, this follow-up was prolonged for 1 more year. Patient data were compiled by experienced clinicians during initial assessment and alongside the 1-year follow-up through patient self-reports, but also through interviews with informants (family members, social professionals) and clinical sources (general practitioner, psychiatrist, etc.). The areas covered were the characteristics of the index episode, those of the population at the time of the index episode, as well as those of the 1-year follow-up including observance to the care and potential repetition of the suicide attempt. The mean age was 14 years with a minimum of 7 years 9 months. The vast majority of the population was female (86.1%), less than one-third lived with both parents, and 27% had academic problems. The most frequent means of suicide attempt was medication (83.9%), 92.6% of adolescents were hospitalized following the index episode, only 7.5% of them were admitted to adolescent psychiatric unit inpatient care following the initial care. Psychiatric evaluation was documented for 93.3% of the adolescents. Half (n=222) had at least one symptom of a psychiatric disorder. One-year follow-up data were available for 394 adolescents: 40 had not yet completed the year and 83 were lost to follow-up. Among the analyzable population of 391 adolescents, 35.3% were optimally observant of the care proposed and 21.4% did not observe treatment. Fifty-nine youths (15%) were referred to the hospital because of a repeated suicide attempt. Two of the patients who repeated the suicide attempt within the year had died. The findings from this study are informative with regard to prevention and intervention efforts with suicidal young and very young adolescents. First, repetition of the suicide attempt in young adolescents is not rare since nearly 15% of the cohort were repeaters within the year following the index episode. Nevertheless, intensive care and follow-up resulting in good attendance appeared to have a positive impact on the repetition of the suicide attempt.

Il estmaintenant prouve que la chimiotherapie (CT) et la radiochimiotherapie (RTCT) preoperatoire augmentent le taux de resection R0 et la survie globale. En plus, la RTCT entraine environ 30 % de reponses completes pathologiques. Par ailleurs, deux essais randomises ont montre que la survie etait similaire apres RTCT a visee curative ou apres RTCT preoperatoire suivie de chirurgie; ces resultats ont ete obtenus dans les cancers epidermoides localement avances, malgre des recidives locales plus frequentes. Dans l’un des essais (FFCD 9102), seuls les repondeurs cliniques a la RTCT etaient randomises entre chirurgie ou non; ainsi, les non-repondeurs pouvaient etre operes sans delai. De fait, les patients randomises et les nonrepondeurs operes avaient une survie non differente. Le benefice de la chirurgie est moins evident pour les recidives plus tardives. Quelques petites etudes non randomisees ont aborde cette question. Les taux de resection R0 y variaient entre 50 et 87 %, avec une survie a cinq ans de 0 a 33%et une mortalite operatoire de 12,5 a 25 %. Un changement radical de strategie se profile dans le cancer de l’oesophage, a savoir commencer par une RTCT a visee curative et n’operer que les nonrepondeurs ou les rechuteurs resecables. Avant de recommander cela, le benefice de la resection « de sauvetage » pour recidive retardee devra etre evalue dans un essai randomise strategique, actuellement en preparation par la FFCD et la FRENCH.

Resume Introduction La fracture apres ablation du fixateur externe dans le cadre des allongements progressifs du membre inferieur represente l’une des principales complications. Elle est retrouvee a des taux allant jusqu’a 50 % dans la litterature. Le but de l’etude est de determiner quels facteurs influencent la survenue de cette complication. Patients et methodes Cent onze allongements de membres inferieurs ont ete realises chez 58 patients (40 femurs et 71 tibias). L’âge moyen au moment de l’operation etait de 10,1 ans. Tous les cas ont ete allonges exclusivement a l’aide d’un fixateur externe, associe dans 39,6 % des cas a la mise en place de materiel centromedullaire. Les patients ont ete repartis en trois categories selon leur etiologie (congenitale, achondroplasie et autres). Les fractures ont ete classees selon la classification de Simpson. Resultats Vingt fractures ont ete repertoriees (18 %). Seize des fractures ont ete retrouvees dans la pathologie congenitale, quatre dans la pathologie achondroplasique et aucune dans le dernier groupe rassemblant toutes les autres etiologies. La fracture interessait plus souvent le femur (27,5 %) que le tibia (12,7 %). Discussion Le taux de fracture est influence par des facteurs differents selon l’etiologie. Dans la pathologie congenitale, le taux de fractures est plus important quand le taux d’allongement depasse 15 % de la longueur initiale et le delai de latence inferieur a sept jours. Dans la pathologie achondroplasique, la notion de pourcentage d’allongement relatif est moins importante que dans la pathologie congenitale. Cependant, il semble preferable pour eviter toute fracture, d’attendre l’âge de neuf ans pour debuter un allongement. De plus, lorsque le fixateur est mis en place, il faut attendre un delai de sept jours avant de debuter l’allongement. Niveau de preuve 4. Type d’etude Retrospective.

Resume Introduction Les fusions instrumentees utilisant des montages par vis pour les scolioses idiopathiques de l’adolescent (SIA) donnent de bons resultats en termes de correction coronale. Cependant, elles peuvent etres responsables d’une perte de cyphose, elle-meme source d’un aplatissement de la lordose. Inversement, la realisation de montages hybrides a ete rapportee comme superieure dans la restauration de la cyphose thoracique (CT). L’objectif de ce travail etait de comparer au sein d’une serie de montages hybrides les resultats en fonction de l’utilisation de vis mono- ou poly-axiales. Patients et methodes Soixante patients (âge moyen 15 ans) porteurs d’une SIA de type Lenke 1, 2 ou 3 ont ete inclus dans ce travail et analyses retrospectivement. La procedure chirurgicale consistait en un montage hybride avec une pince lamolamaire en compression a la partie craniale, des vis pediculaires entre la derniere vertebre instrumentee et T11 a la partie caudale et des liens sous-lamaires entre les extremites du montage. Des vis mono-axiales etaient utilisees pour les 30 premiers patients (groupe MONO) et des vis poly-axiales pour les 30 suivants (groupe POLY). La comparaison etait ensuite realisee en termes de correction de l’angle de Cobb thoracique et de la cyphose T4–T12 a trois mois postoperatoires, par l’intermediaire d’un test de Student. Resultats Sur l’ensemble de la serie, il n’existait pas de difference significative sur l’ensemble des parametres etudies en preoperatoire. Au dernier recul, l’angle de Cobb residuel etait significativement plus eleve dans le groupe POLY que dans le groupe MONO (20,3° vs 15°) avec un pourcentage de correction de 72,1 % dans le groupe MONO vs 64,8 % dans le groupe POLY. Dans le plan sagittal, il existait une difference significative entre les cyphoses thoraciques du groupe POLY (26,6°) et celles du groupe MONO (23°). Discussion Cette etude preliminaire montre que meme au sein des montages hybrides, moins pourvoyeurs de dos plats iatrogeniques, des differences existent selon les techniques utilisees. L’importance de l’equilibre sagittal du rachis est largement decrite dans la litterature et les desequilibres sagittaux notamment iatrogenes sont correles a de moins bons resultats cliniques dans les deformations rachidiennes de l’adulte. Il est donc fondamental de reflechir a l’importance de la correction chirurgicale souhaitee, et il est selon nous preferable de privilegier la correction dans le plan sagittal au detriment d’une legere diminution de la correction dans le plan coronal. Des etudes supplementaires a long terme seront cependant necessaires afin de confirmer ces resultats initiaux. Niveau de preuve IV, serie retrospective.

Proximal junctional kyphosis (PJK) is a frequent proximal adjacent segment disease following spinal fusion in adolescent idiopathic scoliosis (AIS) and its rate has been estimated to 28% in the literature. The etiology is multifactorial, and risk factors associated with PJK are controversial. The aim of this study was to demonstrate that the disruption of muscular and bony tissue above the upper instrumented vertebra (UIV) during surgery does not increase the rate of PJK in patients undergoing posterior fusion for adolescent idiopathic scoliosis. 50 patients with AIS operated between June 2014 and January 2016 were included. Every patient underwent a long posterior spine arthrodesis with a hybrid construct (proximal lamino-laminar claw, thoracic sublaminar bands and lumbar screws). The dissection of posterior elements above the UIV was necessary for the placement of proximal anchors. Radiographic analysis including proximal junctional angle, spino-pelvic parameters (cervical lordosis, thoracic kyphosis TK, lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope) and sagittal vertical axis were collected preoperatively and postoperatively at the last control. The numbers of fused levels, locations of upper instrumented vertebra, locations of lower instrumented vertebra, length of fusion segments were also recorded. Multiple odd ratios and other statistical analysis were performed to evaluate the relation between PJK and the potential risk factors. There were 43 females and 7 males with a mean age of 14.8 years at surgery. PJK occurred in 5 out of 50 cases with an incidence of 10%. The mean follow-up was 18 months. There was no significant difference in gender (OR 1.36, p = 0.8), decrease of TK (OR 1.63, p = 0 0.69), location of UIV (OR 2.25, p = 0.4), LIV (OR 2, p = 0.55), and SVA change (OR 1.63, p = 0.46). The disruption of ligamentous and bony tissue proximal to the UIV during the surgery does not increase the rate of PJK. Level of evidence IV.

International audience; Tropheryma whipplei was detected in preliminary studies in faeces of young children with diarrhoea and also in faeces of asymptomatic persons, not only in Europe but also in Africa. In this study, the link between this bacterium and the presence of acute diarrhoea was evaluated in a large group of children. From December 2009 to January 2013, rectal swabs collected from 3796 children in the emergency departments of university hospitals in Marseille, France, were analysed: 555 children (245 female and 310 male, from 6 days to 6 years old) with acute diarrhoea defined as at least three loose stools per day for

The free vascularised fibular flap (FVFF) is widely used to treat bone defects, although it must be harvested from a healthy site. The objective of this study was to assess clinical morbidity and radiological changes at the FVFF donor site in children.Distal fibular stabilisation using a tibial strut decreases the prevalence of valgus ankle deformity.Thirty-one children managed at two centres between 1994 and 2014 were included. Mean age was 8.9 years (range, 2-14 years) and mean follow-up was 6.6 years (range, 2-21 years). Early and delayed complications were evaluated.Of the 17 early complications, 82.4% resolved fully within 7 months. Valgus ankle deformity developed in 6 (19.4%) patients. Age-residual fibula index under 16 was not significantly associated with valgus ankle deformity, although the P-value was borderline (P0.058). Residual distal fibula length did not predict valgus ankle deformity. Three techniques were used for fibular reconstruction: syndesmotic screw, tibial strut, and both. None of these techniques prevented the occurrence of valgus ankle deformity.Clinical donor-site morbidity after FVFF harvesting, although noticeable, usually resolved promptly. Taken alone, an age-residual fibula index under 16 did not predict valgus ankle deformity. We recommend a distal tibio-fibular quadricortical syndesmotic screw or combined syndesmotic screw-tibial strut fixation to prevent valgus ankle deformity, which is common when a tibial strut is used alone.IV.

Surgical adolescent idiopathic scoliosis (AIS) management can be associated with loss of thoracic kyphosis and a secondary loss of lumbar lordosis leading to iatrogenic flatback. Such conditions are associated with poorer clinical outcomes during adulthood. The aim of this study was to evaluate sagittal plane reciprocal changes after posterior spinal fusion in the setting of AIS. Thirty consecutive adolescents (mean age 14.6 years) with AIS Lenke 1, 2 or 3 were included in this retrospective study with 2 year follow-up. Full-spine standing coronal and lateral radiographs were obtained preoperatively, at 3 and 24 months postoperatively. Coronal Cobb angle, thoracic kyphosis (TK) and lumbar lordosis (LL) were measured. Surgical procedure was similar in all the cases, with use of pedicular screws between T11 and the lowest instrumented vertebra (≥L2), sublaminar hooks applied in compression at the upper thoracic level and sub-laminar bands and clamps in the concavity of the deformity. Statistical analysis was done using t test and Pearson correlation coefficient. Between preoperative and last follow-up evaluations a significant reduction of Cobb angle was observed (53.6° vs. 17.2°, p

Post-traumatic small-bowel obstructions are rare and late complications following blunt abdominal trauma. Timely diagnosis is frequently impeded because of nonspecific associated symptoms, and furthermore, the degree of urgency is frequently underestimated due to the accidental cause. During the last 6 years (2005-2011), we have observed only 2 cases (4 and 10 years old) with post-traumatic small-bowel obstruction. On admission the patients had a contusion on the abdominal wall, duodenal hematoma and a Chance fracture of the lumbar spine on the computed tomography (CT) scan. Although early clinical improvement was noted, progression of the disorder was observed for the following 15 days like an occlusive syndrome (abdominal distension, nausea, emesis). Abdominal ultrasound and computed tomography scan revealed small-bowel obstruction. At laparotomy, jejunal stenosis was found associated with mesenteric tears, which was resected with end-to-end anastomosis. Six to 8 months of follow-up ascertained the therapeutic efficacy of the procedure. Post-traumatic small-bowel obstructions are rare; the clinical presentation is unspecific and appears with a time lag following the trauma. Echography and computed tomography scan can establish both the diagnosis and therapeutic choice.

Resume Les pertes de substances osseuses (PSO) d’origine traumatique sont rares chez l’enfant. Dans la litterature il n’existe aucune serie pediatrique. Le but de ce travail sur la premiere serie pediatrique etait d’en determiner les caracteristiques epidemiologiques et d’evaluer les resultats des differents traitements. Patients et methode Cette etude retrospective multicentrique a porte sur des PSO diaphysaires pour lesquelles une reconstruction a ete realisee. La PSO etait soit initiale contemporaine du traumatisme, soit secondaire en rapport avec une pseudarthrose septique. Resultats La serie comportait 27 patients (17 garcons et dix filles) d’âge moyen 11,4 ans (3–16) (20 accidents de la voie publique). Tous presentaient une fracture ouverte (un stade 1, sept stade 2, 11 stade 3A et sept stade 3B, 1 non renseigne). La PSO interessait 13 tibias, neuf femurs, trois humerus, un radius et un ulna. La PSO etait initiale dans 20 cas et secondaire dans sept cas ; inferieure a 2 cm deux fois, entre 2 et 5 cm neuf fois, comprise entre 5 et 10 cm dix fois, superieure a 10 cm six fois. Le traitement de la PSO a ete immediate dans un cas et differe dans 26 cas. Les techniques utilisees ont ete : membrane induite dans dix cas ; transport osseux dans sept cas ; autogreffe osseuse dans huit cas, fibula vascularisee dans un cas, aucun comblement dans un cas. La consolidation a ete obtenue chez les 27 patients. Le delai de consolidation moyen etait de 12,3 mois (3–62). Quinze patients presentaient des sequelles. Discussion Les PSO d’origine traumatique ont un pronostic meilleur chez l’enfant que chez l’adulte. Le perioste plus epais, plus actif et richement vascularise chez l’enfant est un facteur pronostique important. Le traitement de la PSO necessite une bonne stabilisation initiale. La reconstruction depend de l’integrite du perioste. En cas de perioste intact un apport osseux ne parait pas necessaire chez l’enfant jeune. Si une partie du perioste est intacte, une simple autogreffe parait suffisante meme pour des PSO etendues. En l’absence de perioste ou a fortiori en cas d’infection le choix se portera vers la technique de la membrane induite, un transport osseux ou un transfert osseux vascularise. Niveau de preuve IV etude retrospective.

Resume La perte de substance osseuse (PSO) diaphysaire est un probleme difficile a resoudre en traumatologie en raison notamment des lesions des parties molles et de la frequence d’une infection associee. Le Symposium 2010 de la Societe francaise de chirurgie orthopedique et traumatologique (Sofcot) a permis de confirmer les conclusions issues d’experiences anterieures isolees. L’etude, retrospective et multicentrique, a concerne 204 dossiers de PSO diaphysaires des os longs (humerus, radius, ulna, femur, tibia). Les techniques de reconstruction osseuse etaient les greffes traditionnelles, les transferts vascularises, les techniques de mobilisation osseuse, la technique de la membrane induite et la technique de Papineau. La consolidation a ete acquise dans 93 % des cas, dans un delai moyen de 14,7 mois. Le delai de consolidation n’etait pas lie a l’etendue de la perte de substance et etait similaire quelle que soit la technique. La technique de la membrane induite, par la simplicite de sa mise en œuvre et son caractere programme en deux temps en cas d’infection, a ete la technique la plus utilisee dans cette serie. Les facteurs de mauvais pronostic etaient l’infection, les lesions importantes des parties molles et l’exposition initiale du foyer de fracture. Les grands principes qui gouvernent la reconstruction d’une PSO sont la guerison prealable de l’infection associee et la reparation des parties molles chaque fois que faire se peut. La tendance actuelle est a l’hybridation des procedes de reconstruction en elaborant des strategies s’appuyant a la fois sur le raccourcissement delibere, toutes les formes de greffe traditionnelle, la mobilisation osseuse et la membrane induite. Au segment jambier, la greffe intertibiofibulaire doit etre consideree comme la cle de voute de toute reconstruction etendue. Niveau de preuve Niveau IV : etude d’observation retrospective.

Resume L’analyse de la posture rachidienne a recemment beneficie de l’apport des technologies de reconstructions tridimensionnelles qui ont permis d’ameliorer notre comprehension de cet equilibre dynamique. L’objectif de ce travail est de presenter les resultats preliminaires d’un protocole tridimensionnel d’analyse de la posture, permettant de s’affranchir de certaines contraintes radiologiques et d’evaluer la posture selon une nouvelle approche tenant compte des efforts nets fournis au niveau de differents centres articulaires. Ces resultats preliminaires montrent la faisabilite technique du protocole. Son developpement ulterieur et son utilisation clinique pourront permettre une meilleure comprehension des troubles de l’equilibre postural et l’evaluation de l’impact des corrections chirurgicales sur l’equilibre du rachis.

Resume Les aplasies tibiales sont des pathologies de prise en charge difficile entrainant parfois la necessite d’allongements importants. Dans ces situations, la preservation articulaire reste la regle. Cependant, lorsque cette fonction n’est pas assuree, il est envisageable de realiser un allongement a point de depart articulaire suivi d’une arthrodese. Nous presentons, dans ce travail, les resultats cliniques et radiologiques d’un patient traite par allongement a point de depart intra-articulaire (ou arthrodiastasis) complete par une arthrodese talocrurale. Cette technique originale nous a permis d’obtenir un resultat satisfaisant mais reste, cependant, un programme chirurgical lourd.

Summary Study objectives Describing and assessing of a new surgical procedure to achieve circumferential fusion and translumbosacral fixation using a custom-made canulated screw. Patients and methods Seven patients aged 13–18 years old underwent surgery with this technique (mean age: 15). All patients had high-grade spondylolisthesis (Meyerding stage III or IV). There were five girls and two boys. A posterior surgical approach alone was used in all cases. The posterior neural arch of L5 was removed and a sacral laminectomy, extending to S2, was performed. Sacral nerve roots S2 and S3 were carefully dissected and transposed. A K-wire was placed medially across the vertebrae from the posterior edge of S2 extending to the anterosuperior corner of L5. Fluroscopic perioperative fluroscopic control confirmed correct K-wire placement. The custom-made 10 mm diameter canulated screw was then inserted along the K-wire as a guide. Screw fixation was obtained by placing a specific large diameter screw head to obtain compression by a lag screw effect. Once fixation was obtained, the sacral dome was excised and interbody fusion was performed (tricorticocancellous graft on each side of the screw). Additional bilateral posterolateral fusion was then performed. A half body custom fit thoracolumbar orthosis brace was prescribed 3 months postoperatively, followed by a Lombostat flexible lumbar support for an additional 3 months period. Results One neurological complication occurred. A dural tear occurred during dissection requiring simple repair. All of the patients were on their feet on the fifth postoperative day and began walking. The half bodybrace was worn for 4 months in four patients and 2 months in the three others. At final follow-up patients had no residual pain. Discussion The lumbar spine in children with high-grade spondylolisthesis adapts to the new mechanical conditions after surgery. Therefore the principal goal of treatment is to obtain stable osseous fusion. Our treatment philosophy is based on the concept of a dual instability. We believe that a general instability exists which causes the development of spondylolisthesis; this must be respected by not attempting to correct the displacement beyond what can be obtained on the operating table with complete muscle release. The other, locoregional instability, must be stabilized during circumferential fusion. The custom-made, 10 mm screw has been shown to be effective in neutralizing the mechanical stress during circumferential fusion with a posterior approach alone, thus avoiding the risks of an anterior approach. Long-term results show that the preoperative posture is not the sole mechanical determinant in children and adolescents but that this posture is largely a reaction to pain. Level of evidence Level IV. Retrospective study.

Resume Objectif Description d’une nouvelle procedure chirurgicale permettant la realisation d’une arthrodese circonferentielle et une fixation trans-sacrolombaire par l’intermediaire d’une vis sur mesure. Patients et methodes Sept patients âges de 13 a 18 ans ont ete operes selon cette technique (âge moyen 15 ans). L’ensemble des patients etait porteur d’un spondylolisthesis de haut grade (stade III et IV de Meyerding). Il y avait cinq filles et deux garcons. A chaque fois, l’approche fut uniquement posterieure. L’arc posterieur de L5 etait entierement enleve, puis une laminectomie sacree jusqu’en S2 etait realisee. Les racines S2 et S3 etaient prudemment dissequees et relevees. Une broche etait ensuite placee medialement au travers des vertebres du bord posterieur de S2 jusqu’au coin anterosuperieur de L5. Un controle scopique peroperatoire permettait d’assurer la bonne position de la broche. La vis sur mesure, d’un diametre de 10 mm etait ensuite introduite en utilisant la broche comme guide. La fixation de la vis se faisait ensuite par la mise en place d’un bouchon specifique de diametre plus important permettant de realiser une compression de l’ensemble. Une fois la fixation effectuee, le dome sacre etait retiree et une fusion intersomatique etait realisee (greffe tricorticospongieuse de chaque cote de la vis). Il etait ensuite effectue une fusion posterolaterale bilaterale additionnelle. En postoperatoire, un corset hemiculotte etait prescrit pendant trois mois, suivi du port d’un lombostat pendant trois mois. Resultats Une complication neurologique a ete notee. Une breche durale fut realisee durant la dissection et a necessite une simple reparation. Tous les patients ont ete leves au cinquieme jour postoperatoire avec reprise de la marche. Un corset hemiculotte postoperatoire a ete porte pendant quatre mois pour quatre patients et pendant deux mois pour les trois derniers. Au dernier recul, aucun des patients ne presentait de symptomes douloureux residuels. Discussion Chez les enfants porteurs d’un spondylolisthesis de haut grade, le rachis lombaire s’adapte aux nouvelles conditions mecaniques. Le principal but du traitement est donc d’obtenir une fusion solide. Notre philosophie de traitement repose sur le concept de la double instabilite. Pour nous, il existe une instabilite generale responsable de la survenue du spondylolisthesis qu’il faut respecter en ne cherchant pas a corriger le glissement au-dela de ce qui peut etre obtenu sur table operatoire en relâchement musculaire complet et une autre instabilite, locoregionale, qu’il faut neutraliser, le temps d’obtenir une fusion circonferentielle. Cette vis sur mesure, de calibre 10 mm, a demontre son efficacite dans la neutralisation des contraintes mecaniques pendant le delai necessaire a l’obtention de cette arthrodese circonferentielle, par une approche posterieure unique, evitant ainsi les risques inherents a un abord anterieur. Les resultats a distance mettent en evidence que la posture preoperatoire n’a pas un determinisme purement mecanique chez l’enfant et chez l’adolescent mais que cette posture repond en grande partie a une recherche d’antalgie. Niveau de preuve IV etude retrospective.

RADIOLOGIE ET IMAGERIE MEDICALE : Musculosquelettique - Neurologique - Maxillofaciale - 31-672-C-10

Il dolore all’anca costituisce un sintomo frequente nel bambino e ricopre un ampio campo di patologie. Si deve ipotizzare l’urgenza terapeutica di fronte a qualsiasi dolore all’anca e, all’occorrenza, si deve indirizzare il bambino verso una struttura idonea nella quale le indagini e il trattamento possono essere condotti rapidamente. L’eta del paziente e un dato essenziale, in quanto le malattie che inducono un dolore all’anca non sono le stesse prima e dopo i 10 anni. Il dolore all’anca si manifesta, di solito, con una zoppia. La rilevazione della temperatura e fondamentale: un dolore all’anca accompagnato da febbre orienta verso una patologia infettiva. La realizzazione di una valutazione complementare con la diagnostica per immagini non e sistematica; in pratica, essa e, spesso, necessaria. La radiografia standard e l’esame di diagnostica per immagini di prima intenzione. L’ecografia e un ottimo esame per evidenziare un versamento articolare. Di fronte a qualsiasi dolore persistente per piu di 3 settimane con delle radiografie normali, si raccomanda fortemente di ripetere gli esami di base e, in caso di risultato negativo, di prescrivere una scintigrafia ossea con tecnezio o una risonanza magnetica. Sono esposte le principali eziologie in funzione dell’eta. L’artrite e l’osteomielite dell’anca sono delle urgenze terapeutiche; il ritardo di inizio del trattamento antibiotico determina la prognosi. Il reuma dell’anca e benigno: il riposo assicura la guarigione. La prognosi dell’osteocondrite dell’anca e tanto migliore quanto piu il paziente e giovane; l’obiettivo del trattamento e quello di assicurare un rimodellamento efficace (testa sferica alla maturita); le sue modalita sono relativamente mal codificate. Qualsiasi dolore dell’anca nell’adolescente deve far ipotizzare un’epifisiolisi dell’anca la cui gestione in ambiente chirurgico e urgente. Le eziologie tumorali, benigne e maligne, richiedono delle equipe pluridisciplinari specialistiche.