Assessment of micro-dose biplanar radiography in lower limb measurements in children.

OBJECTIVES: To evaluate in children microdose protocol compared with low dose for lower limb alignment (LLA) measurements on biplanar radiography. METHODS: Children 6 years or older were included. Height, weight and hip width were measured prior to imaging. Hip width allowed classifying children into morphotype M1 (width <25 cm), M2 (25-35 cm) or M3 (>35 cm) corresponding to predefined acquisition parameters (kV, mA, tube speed). Micro- and low-dose protocols were used alternately, with simultaneous acquisition of frontal and lateral radiographs. LLA measurements were performed by two independent observers (n = 526). In 15 children per morphotype, a third observer performed measurements twice (n = 180). Intraclass correlation coefficients and the dose (delivered, absorbed) were calculated. RESULTS: 100 girls and 160 boys (mean age = 11.7 years) were investigated: 74 M1 (mean BMI, 15.7kg/m2), 149 M2 (19.8 kg/m2) and 40 M3 (30.2 kg/m2). With microdose, inter- and intra-observer agreement was >0.90 for lengths whatever the morphotype, 0.75-0.90 (M1) and >0.90 (M2, M3) for valgus/varus and flexion/hyperextension deviations. Dose reduction reached a factor of 8.5 and 5.4 for the delivered and absorbed dose respectively. CONCLUSIONS: Microdose could be used for LLA measurements in children and permits a significant dose reduction. KEY POINTS: • Lower limb lengths of children can be evaluated with microdose biplanar radiography. • Valgus/varus deviations also can be evaluated with microdose biplanar radiography. • Microdose biplanar radiography significantly reduces delivered and absorbed dose in children.

Prevalence and clinical significance of occult fractures in children with radiograph-negative acute ankle injury. A meta-analysis.

BACKGROUND AND PURPOSE: Plain radiographs may fail to reveal an ankle fracture in children because of developmental and anatomical characteristics. In this systematic review and meta- analysis, we estimated the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture, and assessed the diagnostic accuracy of ultrasound (US) in the detection of occult fractures. METHODS: We searched the literature and included studies reporting the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture. Proportion meta-analysis was performed to calculate the pooled prevalence of occult fractures. For each individual study exploring the US diagnostic accuracy, we calculated US operating characteristics. RESULTS: 9 studies (involving 187 patients) using magnetic resonance imaging (MRI) (n = 5) or late radiographs (n = 4) as reference standard were included, 2 of which also assessed the diagnostic accuracy of US. Out of the 187 children, 41 were found to have an occult fracture. The pooled prevalence of occult fractures was 24% (95% CI: 18-31). The operating characteristics for detection of occult ankle fractures by US ranged in positive likelihood ratio (LR) from 9 to 20, and in negative LR from 0.04 to 0.08. INTERPRETATION: A substantial proportion of fractures may be overlooked on plain radiographs in children with acute ankle injuries and clinical suspicion of fracture. US appears to be a promising method for detection of ankle fractures in such children when plain radiographs are negative.

Three-dimensional measurements of the lower extremity in children and adolescents using a low-dose biplanar X-ray device.

OBJECTIVE: To evaluate three-dimensional (3D) measurements of the lower extremity using a biplanar low-dose X-ray device in children and adolescents. METHODS: Firstly, 3D measurements of eight dried bones were analysed by a biplanar low-dose X-ray device (LDX) using stereoscopic software and compared with 3D computed tomography (CT). Secondly, 47 lower limbs of children and adolescents were studied using LDX two-dimensional (2D) and 3D measurements. Both parts were evaluated for femoral and tibial lengths and mechanical angles, frontal and lateral knee angulations, and the femoral neck-shaft angle. RESULTS: The 3D specimen comparison between LDX and CT measurements showed no significant differences: femoral length (P = 0.069), tibial length (P = 0.059), femoral mechanical angle (P = 0.475), tibial mechanical angle (P = 0.067), frontal knee angulation (P = 0.198), lateral knee angulation (P = 0.646) and femoral neck-shaft angle (P = 0.068). The comparison between LDX 2D and 3D measurements showed significant differences in tibial length (P = 0.003), femoral mechanical angle (P < 0.001) and femoral neck-shaft angle (P = 0.001); other parameters were unremarkable. CONCLUSIONS: The 3D LDX system presented reliable measurements compared with 3D CT. Differences between LDX 2D and 3D measurements were noted in the femoral mechanical angle, femoral neck-shaft angle and tibial length. Moderate to good interobserver agreement for the 3D LDX measurements were found. KEY POINTS: Low radiation dose is essential when assessing potential lower extremity discrepancies. A new biplanar low-dose X-ray device can assess such discrepancies in children/adolescents. This LDX device provides equally reliable 3D measurements as prevalent practice LDX measurements carry good overall interobserver agreement.

Bilateral dysplasia epiphysealis hemimelica of the talus associated with a lower leg intramuscular cartilaginous mass.

Dysplasia epiphysealis hemimelica (DEH), or Trevor disease, is a rare skeletal dysplasia characterised by an osteocartilaginous mass arising from an epiphysis. It affects single or multiple epiphyses in children, usually in the lower limb, predominantly the knee and ankle. Bilateral involvement is extremely rare, with only four cases reported in the literature to date. We report an additional case of bilateral DEH of the talus in a 14-year-old girl with an associated, not previously reported, intramuscular cartilaginous mass of the left lower leg. Clinical, radiological and pathological findings are presented. We emphasise the role of MRI and US in the diagnosis of DEH.

Comparison between anterior cuneiform osteotomy and Dunn procedure in the surgical management of unstable severe slipped femoral epiphysis: A case-control study of 41 patients.

BACKGROUND: There is little consensus on the best treatment algorithm for unstable severe slipped capital femoral epiphysis (SCFE). Subcapital osteotomy, which is one of the surgical options, is performed either anteriorly (anterior cuneiform osteotomy, CO) or laterally with trochanteric osteotomy (Dunn procedure, DP). The CO is technically easier and decreases operating time. Moreover, because the DP was the standard in our department before it was replaced by the CO, we had a series of consecutive patients. Therefore, we did a retrospective case-control study in unstable, severe SCFEs treated by CO versus DP, which is to our knowledge the first one aiming to compare: (1) postoperative complications and in particular avascular necrosis, (2) functional outcome, (3) radiologic findings. HYPOTHESIS: CO is less or just as likely to cause avascular necrosis and has the same clinical and radiologic findings as DP. METHODS: A total of 41 patients (24 girls, i.e. 58.5%) were included between 2005 and 2018: 23 in the CO group and 18 in the DP group. The median age was 12.9 years (range, 11.5-14.9) and the median slip angle 70̊ (range, 62.5̊-80̊) with a median follow-up of 3 years (range, 2-4). Preoperative, intraoperative, and postoperative clinical and radiologic parameters (Southwick and alpha angles, and femoral head-neck offset) were analyzed, and all complications were documented. RESULTS: Two (8.7%) cases of avascular necrosis were reported in the CO group and 6 (33.3%) in the DP group (p=.11), with an overall rate of avascular necrosis of 19.5% (8/41). Five out of the 41 patients (12.2%) underwent a total hip arthroplasty: 1/23 (4.3%) in the CO group and 4/18 (22.2%) in the DP group (p=.16). Two (9.5%) patients in the CO group and 7 (38.9%) in the DP group developed postoperative limping before any arthroplasty was performed (p=.055). The alpha angle at follow-up (54±6.1̊ vs. 59.1±7.2̊; p=.027), Oxford hip score at follow-up (17/60 [range, 14-20] vs. 23.5 [range, 19-27]) (p=.021), operating time (132 min [range, 103-166] vs. 199.5 min [range, 142-215]) (p=.011) and intraoperative bleeding (250 mL [range, 100-350] vs. 300 mL [range, 197-450]) (p=.088) were more favorable in the CO group than in the DP group. CONCLUSIONS: The CO has similar results to DP in the surgical management of unstable severe SCFE. LEVEL OF EVIDENCE: III; retrospective comparative study.

Original bar fixation technique in minimally invasive repair of pectus excavatum in adolescents: A 36-case series.

In pectus excavatum, minimally invasive endoscopic repair is the current gold standard in adolescents. The main postoperative pitfall is bar displacement, making fixation a major issue. We report an original transcostal technique using absorbable USP-2 suture in 36 patients. There was a single case of bar displacement (2.78%; 95% CI: 0.07-14.53). Bar stability was comparable to literature reports; but the present technique avoided the complications potentially incurred by use of metal wire, pericostal fixation points and stabilizers.

Idiopathic scoliosis in children and adolescents: assessment with a biplanar X-ray device.

UNLABELLED: Idiopathic scoliosis is one of the most common conditions encountered in paediatric practice. It is a three-dimensional (3D) spinal deformity. Conventional radiography is still the modality of choice for evaluation of children and adolescents with idiopathic scoliosis, but it requires repeat radiographs until skeletal maturity is reached and does not provide information about spinal deformity in all three planes. A biplanar X-ray device is a new technique that enables standing frontal and lateral radiographs of the spine to be obtained at lowered radiation doses. With its specific software, this novel vertical biplanar X-ray unit provides 3D images of the spine and offers the opportunity of visualising the spinal deformity in all three planes. This pictorial review presents our experience with this new imaging system in children and adolescents with idiopathic scoliosis. KEY POINTS: • The biplanar X-ray device produces two orthogonal spine X-ray images in a standing position. • The biplanar X-ray device can assess idiopathic scoliosis with a lower radiation dose. • The biplanar X-ray device provides 3D images of the spine.

Complications in pediatric spine surgery using the vertical expandable prosthetic titanium rib: the French experience.

STUDY DESIGN: Multicenter retrospective study of 54 children. OBJECTIVE: To describe the complication rate of the French vertical expandable prosthetic titanium rib (VEPTR) series involving patients treated between August 2005 and January 2012. SUMMARY OF BACKGROUND DATA: Congenital chest wall and spine deformities in children are complex entities. Most of the affected patients have severe scoliosis often associated with a thoracic deformity. Orthopedic treatment is generally ineffective, and surgical treatment is very challenging. These patients are good candidates for VEPTR expansion thoracoplasty. The aim of this study was to evaluate the potential complications of VEPTR surgery. METHODS: Of the 58 case files, 54 were available for analysis. The series involved 33 girls and 21 boys with a mean age of 7 years (range, 20 mo-14 yr and 2 mo) at primary VEPTR surgery. During the follow-up period, several complications occurred. RESULTS: Mean follow-up was 22.5 months (range, 6-64 mo). In total, 184 procedures were performed, including 56 VEPTR implantations, 98 expansions, and 30 nonscheduled procedures for different types of complications: mechanical complications (i.e., fracture, device migration), device-related and infectious complications, neurological disorders, spine statics disturbances. Altogether, there were 74 complications in 54 patients: a complication rate of 137% per patient and 40% per surgery. Comparison of the complications in this series with those reported in the literature led the authors to suggest solutions that should help decrease their incidence. CONCLUSION: The complication rate is consistent with that reported in the literature. Correct determination of the levels to be instrumented, preoperative improvement of nutritional status, and better evaluation of the preoperative and postoperative respiratory function are important factors in minimizing the potential complications of a technique that is used in weak patients with complex deformities.

Long-term results in scalp tissue expansion in children.

INTRODUCTION: Tissue expansion is frequently used in scalp repair in children. The short-term complications are well known and described in the literature. Impacts at a distance such as potential deformation of the skull or widening of the scar are not so often presented. The aim of this study is to analyze the results at a distance and the actual impact after scalp tissue expansion in young children. MATERIALS AND METHODS: We clinically reviewed 15 children operated on between May 2002 and April 2008 for scalp tissue expansion.Results Mean follow-up was 3 years and 5 months, and mean age of the patients at the first surgery was 20 months. In 11 cases, we observed a widening of the scar. Only two patients presented with a slight flattening of the skull. All parents were satisfied with the results. Children do not remind or keep no unpleasant memory of the surgical protocol. DISCUSSION: Only rare studies focused on very young children. Most of surgeons fear about the consequences of scalp tissue expansion on cranial bone and thus on cerebral growth in children under the age of 2. But it appears that cranial changes in young children are transient with a return to normal within 6 months after removing the implant. Another common problem is the scar enlargement. According to our results and the review of the literature, it seems essential to perform the suture in two layers associated to local reconstruction on the scar to provide the best cosmetic outcomes. CONCLUSION: Tissue expansion remains a good technique to repair large lesions of the scalp in children. The deformation of the skull spontaneously resolves and does not have any consequence on brain growth. The widening of the scar is a common problem in children but can be reduced by suture in two layers associated with local reconstruction. Moreover, young children do not keep any unpleasant memory of this period and are not susceptible to social pressure.

Results after surgical treatment of thumb duplication: a retrospective review of 33 thumbs.

PURPOSE: Purpose This study reports the results of surgical treatment of thumb duplication in the Clinique d'Orthopédie et de Chirurgie de l'Enfant de l'Hôpital Jeanne de Flandre in Lille (France). Methods Thirty patients (33 thumbs) operated on between 1995 and 2003 are clinically reviewed. Results The mean postoperative follow-up was 3 years and 11 months. According to Wassel's classification, the series included 12 type II duplications, two type III, 14 type IV, two type V, one type VI and two type VII. The surgical approaches consisted of simple resection of the most hypoplastic thumb (16 thumbs), the Bilhaut-Cloquet procedure (ten thumbs) and resection associated with reconstructive surgery (seven thumbs). The Bilhaut-Cloquet procedure was used in three cases for treatment of type IV duplication On the basis of the Tada scoring system, we obtained 24 good results, eight fair results and one poor result. Conclusion Based on our results, we recommend that the Bilhaut-Cloquet procedure be used not only for the treatment of type II duplication when the thumbs are both hypoplastic and symmetric but also for type IV duplication with the same clinical parameters. For the other types of duplications, we consider that resection of the most hypoplastic thumb associated with reconstructive surgery is the best surgical approach. For type VII duplication, ablation of the triphalangeal thumb remains the best option. We do not recommend osteotomy at the first surgery.

Pre- and postnatal diagnosis of limb anomalies: a series of 107 cases.

This is a 3-year retrospective study of 107 cases presenting with limb anomalies detected either on prenatal ultrasound scan, or after birth. These limb malformations are developmental anomalies, and can be isolated, syndromic, or associated with multiple malformations. Cases were ascertained through the prenatal diagnosis center, the pediatrics department, and the feto-pathology department. Several criteria were analyzed including sex ratio, prenatal diagnosis, karyotype, termination of pregnancies, clinical or pathological examination, pediatric or surgical and/or genetic assessment, and whether or not a diagnosis was made. Positional deformities and syndactyly were excluded. Limb anomalies were detected prenatally in 45% of the cases, and a diagnosis was made in 78%, including isolated, syndromic, or chromosomal anomalies. Sixty-one per cent of the infants had follow-up, either pediatric, surgical, or genetic. Prenatal multidisciplinary assessment is fundamental to assist with counseling, as is the post-natal follow-up of the infant. The diagnosis, if made, will obviously influence the information that will be given to the parents and the management of the malformation. If the pregnancy is terminated, feto-pathological examination is essential to help make a diagnosis, and guide recurrence risks. We are currently undertaking a prospective study, and we will develop a protocol of investigations in the future, depending on the type of the malformation identified.