Primary aneurysmal bone cysts in children: percutaneous sclerotherapy with absolute alcohol and proposal of a vascular classification.

BACKGROUND: Percutaneous sclerotherapy is an effective treatment for aneurysmal bone cysts (ABCs). OBJECTIVE: The purpose of this study was to demonstrate the safety and efficacy of sclerotherapy with absolute alcohol and to propose a vascular classification of ABCs based on a retrospective review. MATERIALS AND METHODS: This was a review of children treated with absolute alcohol sclerotherapy for ABC at a single institution from January 1995 until November 2009. Treatment response was evaluated radiographically and clinically. Cyst fluid was classified as clear, partially bloody, or bloody. Presence of any venous drainage of the cyst was assessed by injection of contrast medium into the cyst cavity. RESULTS: Twenty-nine children with ages ranging from 2 to 16 years were included. Treatment response was good in 17 (59%), partial in 9 (31%), and poor in 3 (10%) children. Venous drainage was absent in six out of seven clear-fluid cysts, which we classified as lymphatic. Drainage was present in all seven bloody-fluid cysts, which we classified as venous. In seven partially bloody-fluid cysts, venous drainage was seen in three. CONCLUSION: Sclerotherapy with absolute alcohol is a safe and effective treatment of ABC. We propose classifying ABC as lymphatic or venous and suggest considering ABC intraosseous slow-flow vascular malformations.

Radial osteotomy for the correction of forearm deformities in hereditary multiple osteochondroma.

Forearm deformities are often observed in patients with hereditary multiple osteochondroma, resulting in functional disability and cosmetic impairment. The aim of this study was to assess clinical and radiological outcomes after corrective osteotomy of the radius (COR). We performed a retrospective analysis of clinical and radiologic data from patients with forearm deformities who underwent COR combined with osteochondroma resection between 1978 and 2015. Seventeen patients (17 forearms) were included. The mean (range) age at surgery was 11.8 years (3.2-14.4), and the mean interval between surgery and last follow-up was 8.2 years (2-34.2). Range of motion was moderately increased and postoperative radiological assessments found significant improvements in ulnar variance, radial articular angle, bowing of the radius, and carpal slip. At last follow-up, a loss of ulnar variance correction was noted in 11 cases (mean loss: 4mm). The mean score on the Quick Disabilities of the Arm, Shoulder and Hand self-administered questionnaire was 13.9. Our results show that a forearm deformity in a patient with hereditary multiple osteochondroma is an appropriate indication for COR combined with osteochondroma resection and should be performed at the end of growth. This simple, safe technique corrects bowing of the radius and radius-ulna length discrepancy and could limit the risk of radial head dislocation. LEVEL OF EVIDENCE: IV.

Femoral lengthening in children and adolescents.

Current lengthening techniques are still based on the Ilizarov method and the concept of callotasis. Research and progress in medical devices have led to constant improvement in results. Hexapod fixators allow more precise correction of complex deformities, with shorter learning curve. Associating lengthening by external fixation (EF) to internal fixation (K-wire, intramedullary nail or locking plate) has reduced EF times and complications rates, while improving anatomic and functional results. Lengthening nails provides faster recovery of range of motion and return to activity during lengthening and consolidation, with better psychological tolerance. Lengthening with deformity correction by retrograde nailing has no impact on consolidation. Monolateral EF is a reliable and easy-to-implement technique that is well tolerated by patients. Association to internal fixation gives promising results. Bone healing solidity assessment on plain X-ray is highly subjective, with wide inter- and intra-observer variation; bone mineralization is better assessed in terms of pixel-value ratio (PVR: ratio of pixel value of regenerate to adjacent bone) on picture archiving and communication system (PACS) digitized radiographs, providing objective assessment of callus solidity.

Outcomes of orthopedic surgery in a cohort of 49 patients with X-linked hypophosphatemic rickets (XLHR).

BACKGROUND: X-linked hypophosphatemic rickets (XLHR) is due to mutations in PHEX leading to unregulated production of FGF23 and hypophosphatemia. XLHR is characterized by leg bowing of variable severity. Phosphate supplements and oral vitamin analogs, partially or, in some cases, fully restore the limb straightness. Surgery is the alternative for severe or residual limb deformities. OBJECTIVE: To retrospectively assess the results of surgical limb correction in XLHR (osteotomies and bone alignment except for 3 transient hemiepiphysiodesis). METHODS: We analyzed the incidence of recurrence and post-surgical complications in 49 XLHR patients (29F, 20M) (mean age at diagnosis 6.0 years (± 7.1)). RESULTS: At first surgery, the mean age was 13.4 years (± 5.0). Recurrence was observed in 14/49 (29%) patients. The number of additional operations significantly decreased with age (2.0 (± 0.9), 1.7 (± 1.0) and 1.2 (± 0.4) in children <11 years, between 11 and 15, and >15 years; P < 0.001). Incidence of recurrence seemed to be lower in patients with good metabolic control of the rickets (25% vs 33%). Complications were observed in 57% of patients. CONCLUSION: We report a large series of surgical procedures in XLHR. Our results confirm that phosphate supplements and vitamin D analog therapy is the first line of treatment to correct leg bowing. Surgery before puberty is associated with a high risk of recurrence of the limb deformity. Such procedures should only be recommended, following multidisciplinary discussions, in patients with severe distortion leading to mechanical joint and ligament complications, or for residual deformities once growth plates have fused.

[Fingertip injuries in children]. / Les traumatismes distaux des doigts chez l'enfant.

Traumatisms of distal extremities are frequent in children. They can associate fingertip skin, bone and nail complex injuries. Their severity level is very variable, from simple subungual bruise to distal amputation. Initial care needs careful repair of injured structures. Secondary treatment of sequelae is much more difficult.

Prospective survey of acute osteoarticular infections in a French paediatric orthopedic surgery unit.

The epidemiology of acute paediatric osteoarticular infections (OAI) has recently evolved, mainly due to the improvement of microbiological diagnosis. We conducted a prospective study to analyse the recent epidemiology and the clinical evolution of paediatric OAI in order to validate the adequacy of our probabilistic first-line antibiotic treatment (intraveinous cefamandole + gentamicin). All children suspected of community acquired OAI were included and followed-up for 3 years. The etiologic diagnosis was based on blood cultures, joint aspirations and bone punctures. All osteoarticular (OA) samples were systematically inoculated into blood culture bottles. Real-time universal 16S rRNA and PCR targeted on Staphylococcus aureus, Kingella kingae, Streptococcus pneumoniae and Streptococcus pyogenes were performed twice a week. From 17 March 2007 to 26 February 2009, 98 septic arthritis, 70 osteomyelitis, 23 osteoarthritis and six spondylodiscitis were analysed. A portal of entry was suspected in 44% of cases, including 55% of otorhinolaryngological infections. C reactive protein was the most sensitive inflammatory marker. PCR increased by 54% the performance of bacteriological diagnosis. Among the patients completely investigated (blood culture and OAI samples), there were 63% documented OAI. The main pathogens found were K. kingae (52%), S. aureus (28%), S. pyogenes (7%), S. pneumoniae (3%) and Streptococcus agalactiae (2%). All isolated bacteria were sensitive to the probabilist treatment and outcome was favorable. PCR has significantly improved the performance and the delay of IOA diagnosis in children, for which K. kingae turned out to be the first causative agent. The probabilistic treatment was active against the main bacteria responsible for paediatric OAI.

[Toe walker]. / La marche sur la pointe des pieds.

Toe walking is a frequent situation for a clinic in pediatric orthopedic. It is, in most cases, an idiopathic trouble. Neurologic examination is very important to recognize spastic diplegia or neuromuscular disease. A contracture of the triceps can occur and will require a specific treatment from physiotherapy to surgery. A psychological approach is sometimes necessary.

[Specifics in the reconstruction of individual elements in replantation of the forelimb in dogs]. / Specificnosti rekonstrukcije pojedinih elemenata pri replantaciji podlakta u psa.

The experiment was carried out on the four extremities of six, sexually mature dogs of a different race. Gradual reconstruction of the anatomic structures was performed as a single act after the section of the elements. To reach stability of the forearm we employed different osteosynthetic techniques and succeeded to reconstruct blood vessels, nerves, ligaments and the skin, afterwards. Numerous techniques of suturing material were used. The animals were sacrificed six months after being operated and were exposed to microscopic observation and histological analysis. The results obtained suggested the necessity of a firm osteosynthesis of the forearm bones, use of less traumatic suturing material for suturing both blood vessels and fasciculi when preparating nerves.

[Revascularization of the forelimb in dogs]. / Revaskularizacija podlakta u psa.

Revascularization of the forearm was performed on six mature dogs of a different race. Arteria mediana was cut 2 cm above the fork of the arteria radialis and later sutured with a nonresorptive monofilament thread/Ethilonr/7-0 and 8-0 in diameter. The same process was repeated on the cefalica vein. Arteriographies were performed on the operated extremities, pre-operatively, immediately after operation and while an animal being sacrificed. The subjects were sacrificed six months after the operation. Then microscopic and histological analyses were carried out to assess the quality of the blood vessels at the suturing place. At the place of the blood vessels reconstruction, lumen did not get narrower which indicated that all the vessels were in a perfect functional condition. In a number of dogs a higher collagenic proliferation was noticed, in the vicinity of the blood vessels sutured. In the regenerative process of the arterial wall tunica mediana almost took a predominant position, like in the intact arteria. All the three strata were present with no relevant deviations in structure. In the cefalica vein the regeneration of the connective tissue support of the smooth muscles cells was insufficient. Based on the analysis of the results obtained it might be concluded that after revascularization of the forearm of the dog the regeneration of the blood vessels made the segment functionally capable with the structure not different from the normal one which existed in the blood vessels of the same part of the body.