Dynamic 3D Reconstruction of Thoracic Cage and Abdomen in Children and Adolescents With Scoliosis: Preliminary Results of Optical Reflective Motion Analysis Assessment.

BACKGROUND: In patients with untreated scoliosis or in those with posterior spinal instrumented fusion (PSF), the movements of neither the thoracic cage (ThC) nor the abdomen (ABD) during quiet and deep breathing have been well defined in the literature. The purpose of this study was to evaluate kinematic variations in the ThC and ABD during quiet and deep breathing by optical reflective motion analysis (ORMA) in children with scoliosis. METHODS: The study included 6 healthy children (group A), 7 subjects with untreated scoliosis over 50 degrees (group B), and 8 patients with scoliosis treated by PSF (group C). After anthropometric measurements (standing height, sitting height, arm span, chest perimeter, body weight, body mass index, T1-T12, and L1-L5 length) were obtained, the movements of subjects during quiet and deep breathing were measured with a 10-camera 3-dimensional ORMA system (82 markers) with the subjects in a standard standing position. RESULTS: No significant differences were observed in sex, age, weight, height, or arm span (P>0.05). Significant differences were observed in the chest perimeter, Cobb angle, and body mass index (P<0.05). ThC and ABD movements during quiet and deep breathing decreased significantly in group B and C when compared with group A (P<0.05). Group B showed decreased expansion of the ThC (-52.4% to -58.3%) and relatively increased motion of the ABD compared with groups A and C (P<0.001). However, ABD expansion remained lower in group B than in groups A and C (-32.8% and -5.7%). PSF does not completely eliminate transverse plane kinematics, although a greater reduction was observed at instrumented than noninstrumented levels (-60.8% vs. -35.1%; P<0.05). CONCLUSIONS: ORMA is a useful tool for assessing alterations in the kinematics of the ThC and ABD caused by severe scoliosis and/or PSF. Compared with normal subjects, patients with severe scoliosis had poorer and less effective kinematics of the ThC and ABD. In contrast, operated subjects had better and more effective kinematics of the ThC and ABD, breathing curves, thoracic expansion, and abdominal movements closer to normal compared with patients with severe, untreated deformity. LEVEL OF EVIDENCE: Level III.

Is bone mineral mass truly decreased in teenagers with a first episode of forearm fracture? A prospective longitudinal study.

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

Preliminary evaluation of sagittal and transverse plane cross-sectional variations of the trunk during quiet and deep breathing by optical reflective motion analysis in patients with scoliosis.

Trunk movements during quiet and deep breathing in untreated and in operated patients with scoliosis are not well defined. To evaluate sagittal and transverse plane cross-sectional variations of the trunk during quiet and deep breathing by optical reflective motion analysis (ORMA) in children with scoliosis. Twenty-one patients were divided into three groups: normal subjects (A; n = 6), subjects with untreated scoliosis >50° (B; n = 7) and operated patients (C; n = 8). Standing and sitting height, T1-T12 and L1-L5 length, arm span, chest perimeter, weight and BMI were recorded. Trunk movements of all patients, during quiet and deep breathing, were measured with a 10-camera 3D ORMA system (82 markers) with the subjects in a standard standing position. Groups were comparable with respect to age, sex, height, arm span and weight (P > 0.05). Significant differences were found in Cobb angle, chest perimeter and BMI (P < 0.05). Trunk sagittal and transverse plane movements during quiet and deep breathing decreased significantly in group B and group C when compared to group A (P < 0.05). Surgery does not completely eliminate sagittal and transverse plane kinematics, although the spine is rendered more rigid. This preliminary study involving a relatively limited number of patients outlines ORMA is a useful tool for analyzing sagittal and transverse plane motion abnormalities of the trunk. Trunk kinematics was altered during breathing in unoperated patients with scoliosis >50°. Operated subjects had sagittal plane trunk kinematics closer to normal subjects, although changes were less pronounced at the level of the convex side.

Changes of concave and convex rib-vertebral angle, angle difference and angle ratio in patients with right thoracic adolescent idiopathic scoliosis.

The aim of this study is to describe the radiological changes in rib-vertebral angles (RVAs), rib-vertebral angle differences (RVADs), and rib-vertebral angle ratios (RVARas) in patients with untreated right thoracic adolescent idiopathic scoliosis and to compare with the normal subjects. The concave and convex RVA from T1 to T12, the RVADs and the RVARas were measured on AP digital radiographs of 44 female patients with right convex idiopathic scoliosis and 14 normal females. Patients were divided into three groups: normal subjects (group 1), scoliotic patients with Cobb's angle equal or <30° (group 2) and scoliotic patients with Cobb's angle over 30° (group 3). Overall values (mean ± SD) of the RVAs on the concave side were 90.5° ± 17° in group 1, 90.3° ± 15.8° in group 2 and 88.8° ± 15.4° in group 3. On the convex side, values were 90.0° ± 17.3° in group 1, 86.3° ± 13.7° in group 2 and 80.7° ± 14.4° in group 3. Overall values (mean ± SD) of the RVADs at all levels were 0.5° ± 0.7° in group 1, 4.0° ± 4.8° in group 2 and 8.0° ± 4.0° in group 3. The RVARa values (mean ± SD) at all levels was 1.008° ± 0.012° in group 1, 1.041° ± 0.061° in group 2 and 1.102° ± 0.151° in group 3. RVAD and RVARa values in the scoliotic segment were greater in patients with untreated scoliosis over 30° than in patients with an untreated deformity of <30° or normal subjects. A significant effect between groups was observed for the RVA, RVAD and RVARa variables. Measurement of RVA, RVAD and RVARa should not only be performed at and around the apex of a thoracic spinal deformity, but also extended to the whole thoracic spine.

Cervical spine sagittal alignment variations following posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis.

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

Analysis of concave and convex rib-vertebral angle, angle difference, and angle ratio in patients with lenke type 1 main thoracic adolescent idiopathic scoliosis treated by observation, bracing or posterior fusion, and instrumentation.

STUDY DESIGN: Retrospective review. OBJECTIVE: The aim of this study is to describe the radiologic changes in rib-vertebral angles (RVAs), rib-vertebral angle differences (RVADs), and rib-vertebral angle ratios (RVARas) in patients with Lenke type 1 main thoracic adolescent idiopathic scoliosis treated by observation, bracing, or posterior fusion and instrumentation, and to compare these with normal individuals. SUMMARY OF BACKGROUND DATA: The RVA measurement has been shown to be a valid and reproducible method and its asymmetries are related to age, sex, and laterality patterns of the curvature. However, studies of RVA and RVAD in patients with adolescent idiopathic scoliosis are scarce and there are no data regarding the assessment of the ratio between concave and convex RVA. METHODS: A retrospective chart and radiograph review was carried out for 66 consecutive adolescent female patients with Lenke type 1 main thoracic idiopathic scoliosis and 14 normal counterparts. Patients were divided into 5 groups: normal individuals (group 1); scoliotic patients with Cobb angle <30 degrees (group 2A); scoliotic patients with Cobb angle more than 30 degrees (group 2B), scoliotic patients treated by bracing (group 3), and scoliotic patients treated by posterior fusion and instrumentation (group 4). RESULTS: Overall values (mean ± SD) of the RVAs on the concave side were 90.5 ± 17 degrees in group 1, 90.3 ± 15.8 degrees in group 2A, 88.8 ± 15.4 degrees in group 2B, 87.5 ± 13.3 degrees in group 3, and 86.7 ± 17 degrees in group 4. On the convex side, values were 90.0 ± 17.3 degrees in group 1, 86.3 ± 13.7 degrees in group 2A, 80.7 ± 14.4 degrees in group 2B, 82.9 ± 13.2 degrees in group 3, and 81.7 ± 16.2 degrees in group 4. Overall values (mean ± SD) of the RVADs at all levels were 0.5 ± 0.7 degrees in group 1, 4 ± 4.8 degrees in group 2A, 8 ± 4 degrees in group 2B, 4.7 ± 5.6 degrees in group 3, and 5.1 ± 5.2 degrees in group 4. The RVARa values (mean ± SD) at all levels were 1.008 ± 0.012 degrees in group 1, 1.041 ± 0.061 degrees in group 2A, 1.102 ± 0.151 degrees in group 2B, 1.056 ± 0.078 degrees in group 3, and 1.061 ± 0.071 degrees in group 4. CONCLUSIONS: Convex RVA was smaller than concave RVA between T1 and T10 in all groups of patients. RVAD and RVARa values in the scoliotic segment were greater in patients with untreated scoliosis more than 40 degrees than in patients with an untreated deformity of <25 degrees or in patients, treated by bracing or surgery, with a residual curve of <25 degrees. These measurements are a useful tool in the armamentarium of the surgeon treating spinal deformities and could be used to better characterize the deformity and/or to evaluate effects of brace or surgical treatment.

Intraoperative arthrography for the evaluation of closed reduction and percutaneous fixation of displaced MacFarland fractures: an alternative to open surgery.

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

Talonavicular arthrodesis for the treatment of neurological flat foot deformity in pediatric patients: clinical and radiographic evaluation of 29 feet.

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

Kingella kingae osteoarticular infections in young children: clinical features and contribution of a new specific real-time PCR assay to the diagnosis.

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

Neck osteotomy for malunion of neglected radial neck fractures in children: a report of 2 cases.

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

Assessment of muscular performance in teenagers after a lower extremity fracture.

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

Adolescent idiopathic scoliosis: indications for bracing and conservative treatments.

Adolescent idiopathic scoliosis (AIS) represents the most frequent tridimensional spinal deformity. Progression of curves is linked mainly to the rapid growth around puberty. The natural history can lead to large spinal and thoracic deformities, which could impose surgical treatments. In that specific adolescent period, it is possible with very accurate treatments to alt curves progression. We describe the different types of braces used worldwide their indications, technical applications, results and failures, as well our own experience. The literature agrees that with proper indications that means, still growing patients, and documented progressive curves between 20° and 45°, a well-designed and adapted brace providing a correction of 50% can stop the curve's progression in most of the cases.

Unusual radiologic presentation of monostotic fibrous dysplasia.

Fibrous dysplasia is a benign fibro-osseous lesion that can occur as an isolated skeletal lesion (monostotic form) or affect multiple skeletal sites (polyostotic form). In addition, fibrous dysplasia may be associated with single or multiple endocrinopathies, or with precocious puberty and cutaneous hyperpigmentation in McCune-Albright syndrome. Fibrous dysplasia usually appears as a well-defined radiolucent medullary lesion that is irregular, mildly expansive, and with a hazy opacity classically described as "ground glass" in appearance. In the long tubular bones, fibrous dysplasia may cause expansion of the bone contour with cortical thinning and endosteal scalloping. The shaft is typically involved, but the metaphysis may also be affected. These changes are usually recognizable on plain radiographs, but in cases where the lesion is difficult to visualize computed tomography may be beneficial. However, fibrous dysplasia may present with radiographic features that may mimic other benign fibro-osseous lesions, may be associated with other lesions, and even be confused with certain types of malignancies. We present a case of monostotic fibrous dysplasia in the proximal tibia of an 11-year-old girl with the unusual radiologic features of multifocal lytic lesions and cortical disruption. While most often the clinical presentation, laboratory findings, and imaging studies permit the diagnosis of fibrous dysplasia, in certain cases this may pose a diagnostic challenge. The diagnosis was confirmed by open biopsy.

Association of multiple vertebral hemangiomas and severe paraparesis in a patient with a PTEN hamartoma tumor syndrome. Case report.

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

Low protein intake is associated with impaired titanium implant osseointegration.

UNLABELLED: Low protein intake is highly prevalent among orthopaedic elderly patients. We studied the effects of an isocaloric low protein diet on the resistance to pull-out of titanium rods implanted into rats proximal tibia. Isocaloric low protein intake impairs titanium implant osseointegration, with a decreased strength needed to completely loose the implant and altered bone microarchitecture in its vicinity. INTRODUCTION: Low protein intake is highly prevalent among elderly patients in orthopaedic wards and could retard fracture healing. It was previously shown that reduced protein intake decreases bone strength. Whether dietary protein intake could influence titanium implant osseointegration is unknown. We studied the effects of an isocaloric low protein diet on the resistance to pull-out of titanium rods implanted into rats proximal tibia. MATERIALS AND METHODS: Forty-eight 11-month-old female rats were fed isocaloric diets containing 2.5% (low protein) or 15% (normal protein) casein from 2 weeks before the implantation of a 1-mm-diameter cylindrical titanium rod in the proximal metaphysis of each tibia. Four, 6, and 8 weeks after implantation, the tibias were removed for microCT histomorphometry to quantify bone-to-implant contact and bone trabecular microarchitecture around the implant. Resistance to implant pull-out was tested by recording the maximal force necessary to completely loosen the implant. RESULTS: Pull-out strength was significantly lower in rats fed an isocaloric low protein diet by 6 and 8 weeks after implantation (-43%, p < 0.001 and -42%, p < 0.001, respectively) compared with rats fed a normal protein diet. Bone-to-implant contact was significantly lower in the low protein group 8 weeks after implantation (p < 0.05). Bone-to-implant contact and pull-out strength were correlated (r2= 0.57, p < 0.0001). BV/TV around the implant was 19.9 +/- 2.2% (SE) versus 31.8 +/- 3.3% (p < 0.05) at 6 weeks and 20.1 +/- 1.9% versus 29.8 +/- 3.2% (p < 0.05) at 8 weeks after implantation in the low protein and normal protein intake groups, respectively. Trabecular thickness was 96.2 +/- 3.7 versus 113.0 +/- 3.6 microm (p < 0.01) at 6 weeks and 101.4 +/- 2.7 versus 116.2 +/- 3.3 microm (p < 0.01) at 8 weeks in the corresponding groups. In a structure model index analysis, there was a significant shift to a more rod-like pattern in the low protein diet groups. All these changes were associated with lower plasma IGF-I levels. CONCLUSIONS: Isocaloric low protein intake impairs titanium implant osseointegration, with decreased strength needed to completely loosen the implant and altered bone microarchitecture in the vicinity of the implant.

Instrumented fusion of thoracolumbar fracture with type I mineralized collagen matrix combined with autogenous bone marrow as a bone graft substitute: a four-case report.

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

Apophyseal avulsion fracture of the greater trochanter after slipped capital femoral epiphysis: a case report.

A 13-year-old boy sustained an avulsion fracture of the left greater trochanter eight months after surgical stabilisation of a slipped capital femoral epiphysis on the same side. In this specific case, avulsion of the greater trochanter after slipping of the capital femoral epiphysis may have been facilitated by weakening of the trochanteric physis.

MRI abnormalities of the ischiopubic synchondrosis in children: a case report.

The authors report the case of a five and a half year-old-boy with symptomatic MRI abnormalities of the ischiopubic synchondrosis. The concept of "ischiopubic osteochondritis" is reviewed in the light of modern imaging, and the importance of its differentiation from different pathological entities such as osteomyelitis, tumour, fracture or other pathologic entities is recalled.

Risks and complications of prolonged parenteral antibiotic treatment in children with acute osteoarticular infections.

This study aimed at assessing the prevalence of complications encountered during prolonged intravenous antibiotic (AB) therapy when treating acute osteoarticular (OA) infections in children. We reviewed retrospectively 60 paediatric patients treated in our department between 1988 and 1998 for acute osteoarticular infections (27 with acute haematogenous osteomyelitis, 25 with septic arthritis and 8 with septic osteoarthritis). C-reactive protein, erythrocyte sedimentation rate (ESR), and full blood count were monitored during the entire treatment. Body temperature was recorded three times per day until the fever subsided, and then daily during the remaining hospitalisation. Finally, we listed complications related to the antibiotic therapy and those linked to the presence of a venous catheter. Seventeen allergic reactions to drugs were recorded during the intravenous AB therapy. This complications occurred on average after 24.4 +/- 4.4 days of treatment. The clinical manifestations most often encountered were a delayed rise in temperature and cutaneous symptoms. Blood tests showed an isolated increase in the ESR and eosinophilia (> 1000 eosinophils/ml). Four venous catheters had to be removed, in two cases owing to their obstruction and in two cases owing to an infection. Prolonged intravenous AB therapy is not without complications due to its duration and its mode of administration. Drug allergies to AB constitute a major complication of the treatment. They may render the treatment of subsequent infections problematic and expose these patients to major allergic reactions if they accidentally encounter the molecule incriminated. Moreover, the anaesthetics required to insert a central venous catheter and the need to leave it in place for a prolonged duration constitute another source of potential complications. The duration of i.v. AB therapy could therefore be shortened if the clinical and biological evolution is favourable and the pathogen is identified.

Percutaneous pelvic osteotomy and intertrochanteric varus shortening osteotomy in nonambulatory GMFCS level IV and V cerebral palsy patients: preliminary report on 30 operated hips.

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