Age Influence Upon Glenohumeral Remodeling After Shoulder Axial Rebalancing Surgery in Brachial Plexus Birth Injury.

BACKGROUND: Shoulder rebalancing procedures have been proven to provide satisfactory functional improvements in patients with shoulder external rotation (ER) deficit due to brachial plexus birth injury (BPBI). However, the influence of age at the time of surgery on osteoarticular remodeling remains uncertain. The purposes of this retrospective case series were (1) to assess the age impact on glenohumeral remodeling and (2) to determine an age limit after which significant changes can no longer be expected. METHODS: We reviewed preoperative and postoperative magnetic resonance imaging data of 49 children with BPBI who underwent a tendon transfer to reanimate active shoulder ER, with (n=41) or without (n=8) concomitant anterior shoulder release to restore passive shoulder ER, at a mean age of 72 ± 40 months (19;172). Mean radiographic follow-up was 35 ± 20 months (12;95). Univariate linear regressions were used to assess the influence of age at the time of surgery upon changes of glenoid version, glenoid shape, percentage of the humeral head anterior to the glenoid midline, and glenohumeral deformity. Beta coefficients with 95% CI were calculated. RESULTS: Improvements of glenoid version, glenoid shape, percentage of the humeral head anterior and glenohumeral deformity significantly decreased by 0.19 degrees [CI=(-0.31; -0.06), P =0.0046], 0.02 grade [CI=(-0.04; -0.01), P =0.002], 0.12% [CI=(-0.21; -0.04), P =0.0076], and 0.01 grade [CI=(-0.02; -0.01), P =0.0078] per additional month of age at the time of surgery, respectively. The threshold of 5 years was identified as the age at the time of surgery after which significant remodeling no longer occurred. No significant postoperative changes were observed in patients without glenohumeral dysplasia on preoperative magnetic resonance imaging. CONCLUSION: In the setting of BPBI-related glenohumeral dysplasia, the younger the surgical axial rebalancing of the shoulder, the greater the glenohumeral remodeling seems to be. Such procedure seems to be safe in patients without significant joint deformity on preoperative imaging. LEVEL OF EVIDENCE: Therapeutic-Level IV.

Surgical treatment in child's congenital toe syndactyly: Risk factor of recurrence, complication and poor clinical outcomes.

INTRODUCTION: Surgical treatment of toe syndactyly remains controversial. The strong demand from parents for a cosmetic release is increasing in our societies. But is it worth it? The objective was to assess medium-long term outcomes and to identify the risk factors of recurrence, complication and poor clinical outcomes. METHODS: Sixty-eight toe syndactylies (38 patients) undergoing surgery between 2008 and 2017 with a follow-up higher than two years were included consecutively and retrospectively. Four children (four syndactylies) were lost to follow-up and excluded. The mean age of the first surgery was 3.9 years old (0.8-16.7) and cohort mean follow-up was 6.9 years (2.8-11.2). In all patients, web release with a commissural dorsal flap was performed and associated a cutaneous resurfacing (spontaneous epithelialization, full-thickness skin graft taken from the popliteal crease, or a hyaluronic acid ester matrix). RESULTS: Eighteen syndactylies (28.1%) in 14 patients recurred and one syndactyly required revision surgery. An age of surgery above two years was the only risk factor for recurrence found in univariate (OD = 0.27[0.08;0.85];p = 0.02) and multivariate studies (IC 95% = 0.05-0.68;p = 0.02). Seven complications (11.7%) in seven syndactylies (6 patients) were reported with six keloids (9.4%) and one scar retraction (1.6%). Each complication underwent an additional procedure. African ethnicity (N = 15) represents a risk factor (N = 4/15; OD = 0.12[0.009;0.97];p = 0.02) for keloids formation. Withey's average score is 4.9 (1-11), mean OxAFQ-C score was 52/60 (30-60), 67% would repeat the surgery and 69% felt satisfied at last follow-up. The simple syndactyly would appear less satisfied than complex or complicated (p = 0.02). CONCLUSIONS: Surgical treatment of child's congenital syndactyly involves a risk of recurrence (28%) and potential complications (11,7%). Performed surgical procedure over two years old increase the risk of recurrence. African ethnicity is a risk factor in scarring complication. Only half of simple syndactylies are satisfied and prone to repeat the surgery.

Shoulder internal rotation contracture in brachial plexus birth injury: proximal or distal subscapularis release?

BACKGROUND: In cases of brachial plexus birth injury with internal rotation contracture of the shoulder, the subscapularis muscle may be released proximally, from the subscapular fossa, or distally, along with periarticular soft tissues arthroscopic to the glenohumeral joint. We hypothesized that the indication for each procedure would rely primarily on patients' bone remodeling potential and periarticular soft-tissue contractures, performing proximal releases in patients aged < 4 years and periarticular distal releases in older patients. The purpose of this study was to analyze the outcomes such a strategy could provide. METHODS: All patients presenting with brachial plexus birth injury-related shoulder internal rotation contractures who underwent a subscapularis release were included; in addition, to restore the joint axial balance, the infraspinatus was systematically reanimated with a tendon transfer (ie, latissimus dorsi or lower trapezius) during the same operating time. Chart review yielded preoperative and postoperative clinical and radiographic measurements, including active and passive range of motion of the shoulder in external rotation (ER) with the arm at the side of the body, the modified Mallet score, glenoid version, and the percentage of the humeral head arthroscopic to the middle of the glenoid process. RESULTS: Between July 2012 and January 2018, 28 children were operated on at our institution. In patients who underwent proximal subscapularis release (n = 13), significant improvements were observed regarding active shoulder ER, passive shoulder ER, the modified Mallet score, glenoid version, and the percentage of the humeral head arthroscopic to the middle of the glenoid process, averaging 58° ± 32° (P < .0001), 56° ± 20° (P < .0001), 9.7 ± 3.1 points (P = .0006), 15° ± 10° (P = .0034), and 24% ± 20% (P = .0113), respectively, after a mean follow-up period of 4 years. Following distal release procedures (n = 15), these improvements averaged 26° ± 29° (P = .0024), 27° ± 28° (P = .0011), 3.3 ± 4.1 points (P = .0049), 2° ± 17° (P = .4086), and 4% ± 18% (P = .215), respectively, after a mean follow-up period of 3 years. CONCLUSION: When combined with axial rebalancing of the joint, the proximal release of the subscapularis muscle appears to be sufficient to provide satisfactory functional outcomes in patients with great bone remodeling potential and supple periarticular soft tissues. In older patients, a more comprehensive release of the glenohumeral joint's arthroscopic aspect seems to provide lower but still significant clinical improvements.

Congenital nail abnormalities.

Congenital nail disorders are an uncommon presenting symptom which can be difficult to diagnose and manage. Nail diseases in the pediatric population differ from those in adults in terms of diagnosis, approach and management. In most cases, they do not require treatment and resolve with growth. Physicians need to be able to recognize them, to reassure the parents. The most frequently encountered pathologies associated with nail disorder are syndactyly, acrosyndactyly, symbrachydactyly, macrodactyly, Wassel I thumb duplication, Kirner's deformity and congenital onychodysplasia of the index finger. Treatment usually consists in surgical correction of the deformity. Nail malformation can also be an aspect of a systemic disease. It may provide a clue for screening, and should not be overlooked. Nail conditions can be the first sign of nail-patella syndrome, ectodermal dysplasia, dyskeratosis congenita, epidermolysis bullosa, pachyonychia congenita or lung disease. Medical treatment is therefore discussed on a case-by-case basis.

Nonliving versus Living Animal Models for Microvascular Surgery Training: A Randomized Comparative Study.

BACKGROUND: Ethical and financial considerations have encouraged the use of nonliving models for simulation-based training in microsurgery, such as commercially available chicken thighs. The purpose of this study was to compare the nonliving chicken thigh model to the one currently considered as the standard-namely, the living rat model-in the setting of an initiation microsurgery course. METHODS: Applicants to the 3-day basic microsurgery course of the Paris School of Surgery were assigned randomly to either one group that received the regular training of the school (RT group), including four hands-on sessions using only living rat models, or one group that received a modified curriculum in which a nonliving chicken thigh model was used for the first hands-on session (CT group). During the following session, all trainees were evaluated on living rat models, using a global rating scale and two task-specific scales (knot-tying and anastomosis); rates of anastomosis patency, animal survival, and technique completion were recorded. RESULTS: Ninety-three residents were enrolled. Global rating scale, knot-tying, and anastomosis task-specific scale scores were significantly higher in the CT group ( n = 51) than in the RT group, with mean differences of 2.6 points ( P = 0.0001), 1.3 points ( P < 0.0001), and 1.4 points ( P < 0.0001), respectively. Patency and survival rates were significantly higher in the CT group than in the RT group, with mean differences of 22% ( P = 0.0020) and 27% ( P < 0.0001), respectively; completion rates were not statistically different. CONCLUSION: Subject to the use of validated models, such as the chicken thigh, nonliving animal models are a suitable alternative to the living rat model in microsurgery initial training. CLINICAL RELEVANCE STATEMENT: The use of validated non-living models, such as the chicken thigh, is a suitable alternative to the living rat model in microsurgery initial training.

Induced-membrane technique for lower limb reconstruction after malignant bone tumour resection in paediatric patients: Complication and re-operation rates.

BACKGROUND: The objective of this study was to assess the complication and re-operation rates, evaluate the risk of non-union, and describe the functional outcomes at last follow-up in children and adolescents after lower-limb malignant tumour resection and reconstruction using the induced-membrane technique. HYPOTHESIS: Weight-bearing resumption 6 weeks after the second stage of the induced-membrane procedure promotes bone healing. MATERIAL AND METHODS: The study included 13 patients (9 with osteosarcoma, 3 with Ewing's sarcomas, and 1 with alveolar sarcoma) managed between 2000 and 2020 by oncological femoral or tibial resection followed, at a distance from adjuvant chemotherapy, by reconstruction using the induced-membrane technique. Non-union was the primary outcome measure and the MusculoSkeletal Tumor Society (MSTS) lower-limb functional score was the secondary outcome measure. Mean follow-up was 6.1 years (range, 2.0-12.7). At last follow-up, mean age was 18.1 years (range, 11.0-26.0) and the mean MSTS score was 66.6% (37.0-93.0%). RESULTS: After the second reconstruction stage, 8 complications developed in 6 patients (46%). Either a complication or limb-length inequality required 12 re-operations in 8 patients (61.5%). Non-union occurred after reconstruction in 5 (38.5%) patients. Early resumption of 50% weight-bearing 6 weeks after reconstruction was associated with bone healing (p=0.02). CONCLUSION: The non-union rate was 38.5%. Partial, 50% weight-bearing with two elbow crutches and an orthosis, if allowed by construct stability, may promote bone healing. LEVEL OF EVIDENCE: IV.

Comparative study of 2 commissural dorsal flap techniques for the treatment of congenital syndactyly.

BACKGROUND: Many commissural reconstruction techniques have been described for the treatment of syndactyly. This study is the first to compare long-term results of 2 commissural dorsal flap procedures (T-flap and omega-flap). METHODS: Fifty-nine web-spaces in 39 patients, operated on between 1991 and 2008, were retrospectively analyzed. Thirty-six T-flap and 23 omega-flap procedures were performed using full-thickness skin graft in every case for digital resurfacing. Factors that could affect the long-term outcome were collected, including development of web-creep, clinodactyly, and flexion contracture. Patients were reviewed with a mean follow-up of 5 years and 8 months. RESULTS: Preoperative complexity of syndactyly influenced the development of clinodactyly and flexion contracture. Among the patients who developed clinodactyly, 96% had surgery for complex syndactyly. No difference was found between the 2 flap methods concerning digital deformation and mobility. However, web-creep occurred more frequently after T-flap than after omega-flap procedures (17% vs. 5%). CONCLUSIONS: The combination of either dorsal commissural T-flaps or omega-flaps with full-thickness graft to resurface digits is a reliable technique for the treatment of syndactyly with satisfactory functional and cosmetic results. Long-term results are not influenced by the type of flap. Nevertheless, the omega-flap technique, using 2 triangular lateral-palmar flaps, avoids use of skin graft to cover lateral-palmar aspects of the new commissure, consequently reducing the incidence of web-creep. In cases of syndactyly, the primary prognostic factor is whether the patient has simple or complex syndactyly. In complex syndactyly, the risk of long-term unfavorable results is higher. When complex complicated syndactyly is involved, postoperative complication rates increase. LEVEL OF EVIDENCE: Level III.

Dynamic pediatric shoulder instability: Etiology, pathogenesis and treatment.

Dynamic shoulder instability in children or adolescents, whose glenohumeral growth plates are still open, is a rare condition with an etiology that is hard to decipher. Atraumatic and recurrent forms are most common, contrary to adults. Disruptions to capsule and ligament maturation, muscle balance or bone growth can lead to glenohumeral instability. The etiology assessment, which needs to be multidisciplinary in atraumatic forms, aims to collect the medical history, analyze the direction of the instability, determine whether it is voluntary or involuntary, and look for a history of trauma, connective tissue abnormality, psychological disorder, neuromuscular pathology or congenital malformation. The initial treatment is conservative. It requires a multidisciplinary team when the shoulder instability is voluntary. Surgical treatment is reserved for symptomatic forms that do not respond to conservative treatment and have an impact on daily life and/or sports participation after a minimum of 6 months of well-conducted rehabilitation. The results of surgical stabilization mainly depend on the features of the instability, the anatomical structures damaged and the etiology. Episodes of recurrent instability in children/adolescents with open glenohumeral growth plates can fade in adulthood or can get worse with the development of structural damage. Early detection of poor outcomes and suitable treatment will help to limit the occurrence of osteoarthritis in the medium and long term. LEVEL OF EVIDENCE: Expert opinion.

Training in microvascular anastomosis - A randomized comparative study between chicken thigh specimen and live rat.

Training in microsurgical techniques on live rats is the gold standard, but raises ethical issues related to animal welfare and cost. The aim of this study was to compare acquisition of microsurgical techniques with primary training on chicken thigh specimens. Seventy six students were randomly assigned: 23 to exclusive rat training and 53 to primary chicken-leg training. Both groups were then evaluated on aortic suture and jugular aortic bypass surgery in live rats. The primary criterion for successful anastomosis was the patency test. The survival of the rat, the number of severe vascular wounds and the quality of the dissection were also assessed. Aortic anastomoses were of significantly better quality in the chicken group (p = 0.041). There was no significant difference in the number of serious injuries, rat mortality, or quality of dissection (p > 0.05). For jugular aortic bypass surgery, dissection quality (p = 0.02) and patency test (p = 0.05) were better in the chicken-leg group. There was no significant difference in number of severe wounds or rat mortality (p > 0.05). Students who started their microsurgical training on a chicken leg did not perform worse than those with exclusive live rat training. Initial training on chicken thigh specimens seems to be a reliable alternative to training on live models. LEVEL OF EVIDENCE: Level II - Randomized controlled trial.

Computer aided multiplanar osteotomy using patient specific instrumentation to treat cubitus varus in children.

Cubitus varus deformity is a common complication of supracondylar fractures in children. Anatomic correction is the key to obtaining good functional results and avoiding later symptomatic degradation. Different techniques have been described, mainly lateral closing wedge osteotomy. A medial opening wedge osteotomy seems more intuitive, allowing an anatomic reduction, but it is technically challenging. Two-plane radiographs are too simplistic to appreciate the 3D deformity. With medical imaging and image processing advances, three-dimensional (3D) virtual models of a patient's anatomy can be generated. Rapid 3D printing has allowed virtual simulations of surgical corrections to be transferred to real-world applications in the operating room, allowing more precise and accurate surgery with better 3D corrections. 3D computer modeling with the development of customized drilling and cutting guides allows complex medial opening wedge osteotomy for correction of cubitus varus deformity in immature children with best-fit plate synthesis. LEVEL OF EVIDENCE: IV.

Strategy and clinical outcomes of child foot surgery for macrodactyly.

BACKGROUND: Amputation of the abnormal segment seems to be the reference standard treatment for the surgical management of macrodactyly of the foot in children. Our objectives here were to detail the surgical strategies according to the cause, anatomical characteristics, and static or progressive nature of the macrodactyly and to evaluate the long-term clinical outcomes. HYPOTHESIS: Conservative treatment can be an option in the management of static macrodactyly of the foot in children. MATERIAL AND METHODS: We retrospectively included 24 feet in 19 patients seen consecutively. There were 12 primary and 12 secondary types. The macrodactyly was static in 9 cases and progressive in 15 cases. The treatment consisted in either conservative procedures or amputation of the segment. All patients completed the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) to evaluate their quality of life, shoe wear issues, and satisfaction with their treatment. RESULTS: Mean age at first surgery was 5.8 years (range, 0.5-11.5) and the mean interval between two procedures was 2.3 years (range, 0.3-5.5). Mean number of procedures per foot was 2.2 par pied (range, 0-7). All 9 static forms were managed conservatively. Amputation was performed in 11 of the 15 progressive forms. The mean number of procedures was significantly higher in the progressive forms (4.1 vs. 1.5/pied; p=0.006). Two patients died during follow-up. The remaining 17 patients, with 22 affected feet (primary and secondary in 11 cases; progressive in 14 cases and static in 8 cases) were re-evaluated. Mean follow-up was 9.4 years (range, 2.7-20.6). The final OxAFQ-C score was 46/60 (range, 18-58). Of the 17 patients, 86% would be willing to repeat the same surgical procedures and 77% were satisfied with their treatment at last follow-up. We found no differences between the groups managed with amputation and with conservative treatment regarding quality of life, satisfaction, or shoe size difference. CONCLUSIONS: Conservative treatment deserves a place in the treatment of static macrodactyly of the foot in children. Regarding amputation of the segment in progressive forms, it is important to reassure the patients and parents about the expected results but also to inform them about the risk of requiring repeat surgical procedures. LEVEL OF EVIDENCE: IV, retrospective study.

"Unhappy triad" of the trauma elbow in children: Diagnosis, classification, and mid-term outcomes.

Background: The aim of this study was to describe the epidemiology, physiopathology, and outcomes of elbow "unhappy triad" trauma in children, combining a posterior dislocation, a proximal radius fracture, and a third lesion (i.e. bony or capsuloligamentous injury). Methods: A retrospective bicentric study was conducted between 1999 and 2020. All skeletally immature children who presented to the emergency department and underwent surgery for a proximal radius injury were selected. Among this selection, only patients with two associated ipsilateral elbow injuries (i.e. posterior elbow dislocation and a bony and/or capsuloligamentous injury) were included. Active elbow ranges of motion, Mayo Elbow Performance Score and Quick-Disabilities Of The Arm, Shoulder And Hand scores and standard radiographs were recorded at last follow-up. Results: Twenty-one patients met the inclusion criteria (mean age at surgery = 11.4 years) among 737 selected. The "unhappy triad" diagnosis was made preoperatively in nine cases (bone lesion only), intraoperatively in nine cases, and postoperatively in one case. The third lesions were surgically treated when the lesion was a bony fracture or if the elbow remains unstable between 60° and 90° of flexion (i.e. capsuloligamentous injury). Twenty patients were reviewed (mean follow-up = 5.8 years). The complications and re-operations rates were of 10%. Conclusion: The "unhappy" triad of the child's elbow is a rare injury, where the preoperative diagnosis is frequently missed and lead to 10% of complications and re-operations. Level of evidence: level III.

Acute digit ischemia due to a ruptured digital collateral artery aneurysm in a patient of hemophilia: A case report.

Introduction: Digital artery aneurysms are a rare event but cases have been reported in the literature. The hemostasis disorders make these aneurysms particularly dangerous with potentially irreversible hand complications: Compression of adjacent vascular and nervous structures, embolization of associated thrombi, finger ischemia, and necrosis. Case Report: We reported a case of digital ischemia due to a ruptured aneurysm of a digital collateral artery, leading to the diagnosis of congenital hemophilia A. Hematoma evacuation allowed finger revascularization. Complete symptom resolution required ligature excision associated with Factor VIII supplementation. Conclusion: Aneurysms of the digital collateral arteries are a rare event. In the case of a hemophilic patient, surgical management is necessary, and medical treatment alone is not sufficient. The consequences of a ruptured aneurysm in this type of patient can be serious. A close monitoring is required to ensure the absence of early recurrence.

Use of an external fixator during one-step surgical management of missed chronic Monteggia injuries.

The incidence of untreated Monteggia fracture-dislocations is not insignificant. But there is no consensus as to the surgical indication and best surgical technique to use. Single-stage reduction of the radial head through an elbow arthrotomy and ulnar osteotomy is a complex surgical procedure that requires stabilization of the ulnar segments during every step of the intervention. Here, we describe the possibility of using an external fixator intraoperatively to facilitate the various steps of the procedure: (1) gradual distraction and angulation of the osteotomy site to allow thorough excision of any interposed capsular tissue, (2) stable hold on the ulnar fragments independent of the surgical assistant, which allows the stability of the radial head reduction to be tested in pronation and supination and (3) facilitation of plate fixation at the ulnar osteotomy site. LEVEL OF EVIDENCE: IV; case series.

3D planning and patient-specific surgical guides in forearm osteotomy in children: Radiographic accuracy and clinical morbidity.

INTRODUCTION: Three-dimensional (3D) planning and patient-specific surgical guides are increasingly used in the treatment of skeletal deformities. The present study hypothesis was that they are reliable in forearm osteotomy in children, with low morbidity. MATERIAL AND METHODS: Twenty-there children with one or several osteotomies to correct forearm deformities were retrospectively included: 9 (20 osteotomies) with surgical guide (G+), and 14 (28 osteotomies) without (G-). Etiologies comprised 8 cases of Madelung disease (3G+, 5G-) and 15 of post-traumatic malunion (6G+, 9G-). Mean age at surgery was 14.8±1.9 years. The patient-specific 3D-printed polyamide guides were produced from 3D virtual models based on 3D CT reconstruction. Mean follow-up was 22.1±13.6 months. RESULTS: Mean correction error was 5.3°±4.1 and 4.2°±4.1 in the frontal and sagittal planes respectively in G+ (p=0.6). Surgery time was significantly shorter in G+, by a mean 42min (p=0.02). Mean total radiation dose (preoperative CT+intraoperative fluoroscopy) was significantly higher in G+ (p<0.0001). Complications rates were similar between groups. Improvement in PRWE score was significantly greater in G+. CONCLUSION: The present preliminary results were encouraging. 3D planning and patient-specific surgical guides can be used in the treatment of forearm deformity in children. LEVEL OF EVIDENCE: III; retrospective cohort study.

Surgical release of the pediatric trigger thumb.

PURPOSE: The spontaneous recovery rate for locked pediatric trigger thumb (PTT) has recently been reported at between 24% and 66%; these studies concluded that a conservative approach for this condition could be adopted. The aims of this study were to review our results of surgical release of the PTT and to survey pediatric hand surgeons regarding their practice patterns for treatment of the PTT. METHODS: After institutional review board approval, we retrospectively reviewed 173 consecutive patients with 217 thumbs treated surgically at our institution. An e-mail survey of 27 pediatric hand surgeons questioned treatment of a 2-year-old child with a 6-month history of a locked trigger thumb and of an intermittently triggering thumb. RESULTS: The retrospective review demonstrated that preoperative range of motion averaged 36° loss of extension (range, 0° to 90°; SD, 22°); postoperative range of motion averaged 1° loss of extension (range, 0° to 30°; SD, 7°) at 27-day follow-up. Using a parent questionnaire at an average follow-up of 4.2 years, there were no major complications or recurrences identified. Five thumbs developed minor skin complications that healed with conservative management. There were no secondary surgeries. The practice pattern survey demonstrated that 85% of pediatric hand surgeons would treat a locked PTT in a 2-year-old with surgical release and 52% would treat an intermittently triggering thumb in a 2-year-old with continued observation if the triggering thumb was not painful. CONCLUSIONS: The surgical results reported in this study, along with the practice pattern survey, confirm that surgical release is a short, safe, and effective procedure when performed by specialty trained hand surgeons, and it is the treatment of choice for a locked PTT.

Thoracoscopy in children less than 20 kg for the management of spinal disorders: efficacy at long-term follow-up.

BACKGROUND: Thoracoscopy is now considered a safe and feasible method for surgical management of spinal disorders in both adults and children. Nevertheless, a weight less than 20 kg has been reported as a relative contraindication because of the small volume of the thoracic cage and the anticipated difficulties of single-lung ventilation. The aim of this study was to evaluate the feasibility, as well as the safety and efficacy, of thoracoscopic procedures in such patients. METHODS: This study was a retrospective analysis of a consecutive group of patients less than 20 kg weight, who underwent a thoracoscopy between 1998 and 2005. Results were evaluated radiologically, and intraoperative and postoperative complications were reported. A minimum 2-year follow-up was required. RESULTS: Seventeen patients were included. Age at surgery averaged 3 years and 4 months (±1.25). The mean weight was 13.3 kg (±2.8). Fourteen of the patients had congenital scoliosis, 9 due to hemivertebrae and 5 due to segmentation failures. The other 3 suffered from evolutive kyphosis, 2 caused by Pott disease, and 1 caused by congenital anterior failure of segmentation. The mean follow-up was 6 years and 9 months (±1.5). Lung exclusion time averaged 114 minutes (±20). The intended procedure was possible in all cases and no conversion to open thoracotomy was required. The mean operating time was 139 minutes (±10). A posterior arthrodesis was associated and performed during the same anesthesia in 15 cases. The selective breathing was efficient and well tolerated in all cases. No intraoperative respiratory complication was observed. For patients with congenital scoliosis, the average improvement of the main curve between preoperative and latest follow-up was 55%, with an average Cobb angle improvement of 19.1 degrees (±10.5). For the 3 cases of kyphosis, the curve progression stopped, with a mean reduction of the regional kyphosis of 6 degrees (±11.5). Fusion was obtained radiologically in all cases. CONCLUSIONS: This study confirms the feasibility, safety, and efficacy of thoracoscopy for the management of spinal disorders in children less than 20 kg weight. Thoracoscopy can still be considered as an option in very young children, even though the small chest cavity creates additional technical challenges and the diminutive bronchial tree necessitates a dedicated method of single-lung ventilation. LEVEL OF EVIDENCE: IV.

Digital avulsion with compromised vascularization: study of 23 cases in children.

BACKGROUND: Avulsion of a digit has not always been an indication for replantation because of extensive injuries. The advent of microsurgery changed this, permitting avulsed digit replantations with varying rates of success. The aim of this study was to analyze surgical management of finger avulsion injuries of an exclusively pediatric series. METHODS: A retrospective study of children with finger avulsion injuries and compromised arterial circulation degloving or amputation, treated primarily in our institution between 1997 and 2007. Factors that could affect the outcome included demographic and clinical data, description of the lesion using Urbaniak's and Tamai's classification, technical data related to surgery, and results of revascularization were collected. RESULTS: Twenty-three children with 23 digital injuries were identified as digital avulsions with compromised vascularization. The mean age was 11 years and 8 months (range, 2 to 15 y). Four cases involved devascularization classified as Urbaniak 2 and the other 19 cases involved amputation or complete degloving, classified as Urbaniak 3. In 7 cases, replantation was not performed because of the extent of the lesions (all were classified as Urbaniak 3). The complete survival rate when revascularization or replantation was attempted was 25%. One case required a new procedure 6 days after the first surgery with a trans-P2 amputation. Injuries classified as Urbaniak 2 had an overall survival rate of 75% and injuries classified Urbaniak 3 had an overall survival rate of 5.3%. CONCLUSIONS: The global rate of survival after revascularization or replantation of avulsed fingers in children seemed to be poor. Urbaniak classification is an important prognostic factor with a good prognosis for lesions classified as Urbaniak 2 and a very poor prognosis for lesions classified as Urbaniak 3.

Upper limb kinematics after Latissimus Dorsi transfer in children with brachial plexus birth palsy.

BACKGROUND: Brachial plexus birth palsy remains a frequent condition and one of its treatments is to transfer the Latissimus Dorsi tendon to the infraspinatus muscle. The aim of this study was to analyse, for the first time, the three-dimensional kinematic effects of this operation on the upper limb joints during the five Mallet tasks and their correlation with clinical parameters. METHODS: Kinematic analysis was performed using an electromagnetic device. An Index of Improvement taking into account the angle in preop and postop, the reproducibility and the angle of a control group was developed. Three groups of patients were analysed: sixteen patients (mean: 10,5 years) for the reproducibility, thirty children (mean: 9,5 years) for the control group and ten patients (mean: 8 years 7 months) who were operated. FINDINGS: The humerothoracic and glenohumeral external rotations improved during the external rotation, the neck and the abduction tasks and worsened during the spine task. The glenohumeral external rotation worsened during the mouth task. The Humerothoracic abduction improved during the abduction and the neck tasks. The elbow flexion improved for the neck task. Differences were observed between patients and correlations were obtained between the Index of Improvement and clinical parameters. INTERPRETATION: Using kinematics allows to better analyse the evolution of joint angles after the latissimus dorsi transfer. The Index of Improvement allows to quickly analyse the effect of the operation for each angle and each patient. This effect depends on clinical parameters.