Rangeland Rummy - a board game to support adaptive management of rangeland-based livestock systems.

Rangeland-based livestock systems have to deal with the significant instability and uncertainty of the agricultural context (policy changes, volatility of input prices, etc.), and especially of the climatic context. Thus, they are particularly concerned by adaptive management strategies. To support the development of such strategies, we developed a board game including a computer model called "Rangeland Rummy". It is to be used by groups of farmers and agricultural consultants in the context of short workshops (about 3 h). Rangeland Rummy builds upon five types of material object: (i) a game board; (ii) a calendar stick indicating the starting date of the game board; (iii) sticks marked with the feed resources available for combinations of vegetation types and their management practices; (iv) cards to define animal groups and their feeding requirements throughout the year; (v) cards related to types of feed that can be attributed to animal groups throughout the year. Using these material objects, farmers collectively design a rangeland-based livestock system. This system is immediately evaluated using a computer model, i.e. a spreadsheet providing graphs and indicators providing information on, among other things, the extent to which quantitative and qualitative animal feeding requirements are covered across the year. Playing the game thus consists in collectively and iteratively designing and evaluating rangeland-based livestock systems, while confronting the players with new contextual challenges (e.g. interannual variability of weather, volatility of input prices) or new farmers' objectives (e.g. being self-sufficient for animal feeding). An example of application of Rangeland Rummy with 3 farmers in southern France is reported. Applications show that it tends to develop farmers' adaptive capacity by stimulating their discussions and the exchange of locally-relevant knowledge on management strategies and practices in rangeland-based livestock systems.

[OVERUSE INJURIES IN THE YOUNG ATHLETE]. / Lésions osseuses de sollicitation excessive chez l'enfant sportif.

Sport injuries are common in children and teenaggers, especially overuse injuries. Typical musculoskelotal disorders include apophyseal pains or avulsion, stess fractures, and also epiphyseal ostoochondritis. Some lesions are specific according the practice, such spine or wrist lesions. Prevention of sport injury should be the main priority as well for the parents than the coaches and children themselves. Proper education and preparation, specific training and streching are essential for all sports activities.

Reducing environmental impacts of feed using multiobjective formulation: What benefits at the farm gate for pig and broiler production?

Feed production is the main contributor to several environmental impacts of livestock. To decrease environmental impacts of feed, those of feedstuffs should be considered during formulation. In particular, multiobjective feed formulation (MOF) can help reduce several environmental impacts simultaneously while keeping any increase in feed price moderate. The objective of this study was to assess environmental benefits of MOF at the farm gate for fattening pigs and broilers. For pigs, three feeding strategies were tested: classic 2-phase (2P), 2-phase with lower net energy content (2P-), and multiphase (MP). For broilers, two strategies were tested: classic 3-phase (3P) and 3-phase with higher digestible amino acid contents and lower metabolisable energy content (3P+). Diets were formulated using both least-cost formulation (LCF) and MOF, yielding six pig scenarios and four broiler scenarios. Environmental impacts at the farm gate were estimated using a modelling approach based on life cycle assessment. Indicators for six impact categories were then calculated: climate change (CC), cumulative non-renewable energy demand (CEDNR), acidification (AC), eutrophication (EU), land occupation (LO), and phosphorus demand (PD). As expected, MOF had lower farm-gate impacts than LCF (as much as -13%), but the degree of decrease varied by feeding strategy and impact. For pigs, MOF was equally effective in all strategies at reducing PD (-6 to -9%) and AC (-2%). In contrast, MOF was more effective in 2P and 2P- at decreasing CC (-5% to -7%), LO (-9% to -13%) and EU (-6% to -8%) than in MP (CC: -2%; LO: -4%; EU: -3%). The benefit of MOF was found greater in 2P (-7%) than in other pig strategies for CEDNR (-3 to +0%). For broilers, MOF was equally effective in both strategies tested at decreasing PD (-12%), AC (-2%), and EU (-4%). For CC and CEDNR, MOF was more effective in 3P (CC: -9%; CEDNR: -11%) than 3P+ (-6% for both impacts), but not for LO (+3% in 3P vs -1% in 3P+). These differences were due mainly to differences in animal performance (especially feed conversion ratio) among the strategies tested. Finally, in all scenarios, gross margin at the farm gate decreased with MOF comparatively to LCF (pigs: -3% to -11%); broilers: -7% to -11%). These results demonstrate the importance of comprehensive economic and environmental optimisation of feeding strategies by simultaneously considering feed impacts, animal performance, and manure management. To do so, further research is therefore required to develop new modelling tools.

Effects of interactions between feeding practices, animal health and farm infrastructure on technical, economic and environmental performances of a pig-fattening unit.

European pig production faces economic and environmental challenges. Modelling can help farmers simulate and understand how changes in their management practices affect the efficiency of their production system. We developed an individual-based model of a pig-fattening unit that considers individual variability in performance among pigs, farmers' feeding practices and animal management and estimates environmental impacts (using life cycle assessment) and economic results of the unit. We previously demonstrated that this model provides reliable estimates of farm performance for different combinations of management practices, pig types and building characteristics. The objectives of this study were to quantify how interactions between feeding practices and animal management influence fattening unit results in healthy or impaired health conditions using the model. A virtual experiment was designed to evaluate effects of interactions between feeding practices, health status of the pig herd and infrastructure constraints on the technical performance, economic results and environmental impacts of the unit. The virtual experiment consisted of 96 scenarios, which combined chosen values of 6 input parameters of the model: batch interval (35 days and 7 days), use or non-use of a buffer room to manage the lightest pigs, feed rationing (ad libitum and restricted) and sequence plans (two-phase (2P), daily-phase (DP)), scale at which the feeding plan is applied (i.e. room, pen and individual) and health status of the pig herd (i.e. healthy v. impaired). Variance analysis was used to test effects of the factors in these 96 scenarios, and multivariate data analyses were used to classify the scenarios. Healthy populations obtained on average higher economic results (e.g. gross margin of 11.20 v. 1.50 €/pig) and lower environmental impacts (e.g. 2.24 v. 2.38 kg CO2-eq/kg pig live weight gain) than the population with impaired health. With 35 days batch interval and DP feeding, populations with impaired health reached gross margin similar to healthy populations with 2P ad libitum feeding and 7 days batch interval. Restricted, DP and individual feeding plans improved the economic and environmental performances of the unit for both health statuses. This study highlighted that health status of the pig herd is the main factor that affects technical, economic and environmental performances of a pig-fattening unit, and that adequate feeding strategies and animal management can compensate, to some extent, the effects of impaired health on environmental impacts but not on gross margin.

The radioactive ion beam production systems for the SPIRAL2 project.

The SPIRAL2 project, currently under construction at GANIL, will include an isotope separator on line based facility for the production and acceleration of radioactive ion beams. A superconducting linear accelerator will accelerate 5 mA deuterons up to 40 MeV and 1 mA heavy ions up to 14.5 MeV/u. These primary beams will be used to bombard both thick and thin targets. We are investigating three different techniques to produce the radioactive ion beams: (1) the neutron induced fission of uranium carbide, (2) the direct interaction of deuterons in a uranium carbide target, and (3) the interaction of a heavy ion beam with a target. All these production systems will be coupled to an ion source. Four kinds of ion sources are foreseen for the ionization of the radioactive atoms: an electron cyclotron resonance ion source, a surface ionization ion source, a forced electron beam induced arc discharge ion source, and a laser ion source depending on the characteristics of the desired radioactive ion beam in terms of intensity, efficiency, purity, etc. A presentation of the SPIRAL2 project and of the different production systems is given.

[Ankle injury without fracture in children: cast immobilization versus symptomatic treatment. Impact on absenteeism and quality of life]. / Traumatisme de la cheville sans fracture chez l'enfant : immobilisation plâtrée versus traitement symptomatique. Impact sur l'absentéisme et la qualité de vie.

UNLABELLED: Treatment methods for ankle injury in children are numerous and have comparable results. The impact on absenteeism and quality of life is an interesting criterion to consider in order to help doctors in their initial treatment choice. OBJECTIVE: The objective of this study was to compare two therapeutic strategies for ankle injury without fracture in children in terms of the impact on school absenteeism, parents' professional absenteeism, and quality of life. The strategies compared were cast immobilization of the ankle and a purely symptomatic treatment with no immobilization. MATERIALS AND METHOD: We conducted a prospective, comparative, and randomized study. The population comprised children between 8 and 15 years of age, consulting for a first episode of ankle injury in a pediatric-emergency department of a hospital center in Marseille, France. A clinical and radiographical report was systematically done. Children were seen after 1 week to provide the clinical monitoring, assess the child's and parents' absenteeism, and assess the quality of life. RESULTS: Sixty-two patients were studied. There was no difference in clinical progression after 7 days between the two treatment groups. Quality of life was also comparable. However, the children's absenteeism and the parents' absenteeism were higher in the casted group.

[Complications of prophylactic pinning for unilateral upper femur epiphysis slipping: retrospective analysis of 62 operated cases]. / Complications du vissage controlatéral préventif en cas d'épiphysiolyse fémorale supérieure unilatérale : à propos d'une série rétrospective de 62 cas opérés.

PURPOSE OF THE STUDY: The appropriate treatment for unilateral slipping of the upper epiphysis of the femur is controversial. Prophylactic surgical treatment raises the risk of bilateralization. The procedure is often unnecessary as the natural history of epiphyseal slipping is often favorable when the displacement is minimal. We analyzed the complications of systematic prophylactic treatment in order to determine the optimal attitude. MATERIAL AND METHODS: This was a retrospective series of 62 children who underwent surgery for unilateral slipping of the superior femoral epiphysis between 1996 and 2005. Prophylactic treatment of the healthy hip was instituted systematically. The complications were noted according to Paley. We searched for factors of risk of complications, studying the bone maturity indexes, the characteristic features of the healthy femur epiphysis and the surgical technique used. RESULTS: There were seven complications, six following prophylactic treatment and one after material removal. The rate of complications reached 11.3%. Five of the complications were minor: two local infections with favorable outcome and three patients who complained of pain in the hip at mobilization, which had totally resolved at one year. One moderate complication was noted: spiral fracture of the upper femur starting from the screw head and treated with plate fixation. The outcome was favorable. There was one severe complication: osteoarthritis of the hip joint with septicemia on day 3. The outcome was unfavorable with necrosis of the femoral head, resection and use of a spacer. A total hip arthroplasty was performed at one year. DISCUSSION: Complications were globally more frequent and more severe compared to series using prophylactic screwing. The major infection complication (osteoarthritis) observed in this series has not been reported elsewhere. There was probably a center effect since we recruited all of the most complex cases in our region. We were unable to identify any factor predictive of complications. There is apparently no clear choice between systematic prophylactic treatment and careful surveillance. Prophylactic treatment in selected patients might be the key to a successful preventive approach.

[Ankle injuries without fracture in children. Prospective study with magnetic resonance in 116 patients]. / Traumatismes de la cheville sans fracture chez l'enfant. Etude prospective par résonance magnétique de 116 patients.

PURPOSE OF THE STUDY: Appropriate assessment of ankle injuries in children and adolescents is a common emergency room problem. Many imaging techniques have been proposed, but with no consensus on the reality of anatomic lesions in ankles free of fractures, complicating the therapeutic decision. We analyzed the lesions observed with magnetic resonance imaging (MRI) in a large number of acute ankles in children. MATERIAL AND METHODS: This prospective study was conducted in a pediatric emergency room. The study population included all children aged eight to 15 years who presented an isolated injury of the ankle without fracture on the plain x-ray. History taking and physical examination were standardized. MRI was performed within three days of the initial physical examination. All the radiographic documents were examined by an experienced radiologist blinded to the results of the physical examination. RESULTS: During the study period, 116 patients were included. One hundred two MRI series were examined. Minor ligament injury was noted in 20 patients and ligament tear in five, including three with a closed distal tibial growth plate. Minor bone injury was noted in 42 patients and fracture in seven. None of these fractures were visible on the plain x-ray, even after knowledge of the MRI. Injuries were more frequent in boys. Injuries were more frequent when the pain was localized on the lateral aspect of the ankle and when there was an edema. DISCUSSION: Despite an abundant literature on ankle sprains, prospective studies are scarce in the pediatric population. We have found that MRI is particularly well-adapted for children because it allows a complete examination of anatomic lesions involving the bone or ligaments without the inconveniences of injections, pain, or radiation. Our clinical and imaging findings show that ankle sprains are real in children. We were however unable to identify any clinical factors predictive of ligament and/or bone injury. Other studies should be conducted to better understand the nosological context of ankle sprain in children and adolescents. Further study will enable a better evidence-based approach to individually adapted therapy.

[Informative value of the popliteal angle in walking cerebral palsy children]. / Peut-on se fier à l'angle poplité chez l'enfant paralysé cérébral marchant?

PURPOSE OF THE STUDY: In clinical practice, it is generally accepted that hamstring tightness results in incomplete knee extension when the hip is in flexion and in smaller conventional and modified popliteal angles. Similarly, a difference between the conventional popliteal angle and the modified popliteal angle (popliteal differential) would be associated with a permanent deficit in knee extension. The purpose of this study was to determine whether these two hypothesis correlate with clinical findings. MATERIAL AND METHODS: The series was composed of 35 walking cerebral palsy children, 16 girls and 19 boys, mean age 11+/-3.6 years with a pathological conventional popliteal angle. These children walked using the jump knee (n=24) or the crouch knee (n=11) pattern. Permanent hip flexion and the conventional and modified popliteal angles were noted. SPSS version 10.1.3 for Window was used to search for a correlation between the popliteal differential and the presence of permanent hip flexion using several values for the popliteal differential (5, 10, 15, 20, and 30 degrees ). Data were adjusted for age and gender. RESULTS: The statistical analyses demonstrated a significant relationship between the presence of permanent hip flexion and a popliteal differential strictly less than 10 degrees and between the absence of permanent hip flexion and a popliteal angle greater or equal to 10 degrees . These statistically significant results, which demonstrated the opposite of what was expected, were independent of age and gender. DISCUSSION: Our findings demonstrate that examination of the knee joint is indispensable but insufficient. The conventional popliteal angle is not a reliable indicator of hamstring tightness. The normal value of the modified popliteal angle has not been established so that it is impossible to determine what a pathological angle is. We do not know whether measurement of this angle is sufficient to establish indications for surgery. In the future, the development of muscle models coupled with gait analysis should enable more reliable prediction of outcome after surgery. At the present time, we recommend repeated physical examination using a standardized protocol, taking into consideration, several parameters including spasticity, selectivity and muscle force and to perform quantified gait analysis before scheduling hamstring lengthening surgery for walking cerebral palsy children.

[Fat embolism during limb lengthening with a centromedullary nail: three cases]. / Embolie graisseuse au cours des allongements de membres par clou centromédullaire: à propos de trois cas.

Several methods are available for progressive limb lengthening, including centromedullary nailing, external fixation, or a combination. Each technique has its own advantages and drawbacks. In trauma victims, use of centromedullary nailing is associated with potentially fatal fat embolism. This fatal outcome might also occur during limb lengthening, particularly in bilateral procedures. To our knowledge, fat embolism has not been reported with the use of centromedullary nail for limb lengthening. This was a multicentric study of three cases of fat embolism, including one fatal outcome. In all, 36 centromedullary lengthening nails were inserted in the three centers before these acute episodes. The first two cases occurred during single-phase bilateral procedures, the third during unilateral lengthening. Fat embolism could result from several factors, as reported in the literature. While the bilateral nature of the procedure has been incriminated, the observation of an embolism during a unilateral procedure suggests other factors may be involved. Considerable increase in endomedullary pressure during reaming and insertion of the nail has been demonstrated. At the same time, there is the question as to whether the reduction of the diminution of medullary pressure by corticotomy would be an efficient way of reducing the risk of fat embolism. Based on the analysis of our three cases, we suggest that the best way to avoid fat embolism might be to drill several holes within the area of the osteotomy before reaming, in order to reduce endomedullary pressure. This can be achieved via a short skin incision, sparing the periosteum before low energy osteotomy. Since applying this protocol, the three centers have implanted 17 lengthening nails, without a single case of fat embolism.

[Salter and Harris type-II distal femoral physeal fracture-separations at adolescent age: a new therapeutic approach (preliminary study)]. / Fractures-décollements épiphysaires de type SalterII de l'extrémité distale du fémur chez l'adolescent : nouvelle proposition thérapeutique (étude préliminaire).

PURPOSE OF THE STUDY: The prognosis of distal femoral physeal fracture-separation is poor in children. In adolescents, more than half of the cases are classified as Salter and Harris type-II. The gold-standard treatment for a displaced fracture combines anatomic reduction with internal fixation with a pin or screw, preserving the growth cartilage. Despite this treatment, the rate of mid- and long-term complications has been high in the literature, most problems being related to leg length discrepancy and misalignments (genu valgum and genu varum). In order to avoid these problems, for adolescents, we propose and osteosynthesis system which bridges the entire growth cartilage with a blade-plate. Depending on the bone age, puberty and thus potential for further growth, we combine this osteosynthesis with a contralateral distal femoral epiphysiodesis to prevent invalidating leg length discrepancy. MATERIAL AND METHODS: We reviewed retrospectively the cases of 21 patients aged 11 to 15 years treated between 1990 and 2005 for Salter and Harris type-II distal femoral physeal fracture- separation. Clinical and radiographic outcome was compared between the 16 patients treated with the classical internal fixation system or cast immobilization and the five patients treated with a blade-plate. A complete physical examination was available for the follow-up in all cases. A full stance view was used for the radiographic analysis. The mean follow-up was 6.7 years (range 2-17), minimal two years. RESULTS: In patients treated with the classical fixation system or a plaster cast, four of 16 (25 %) developed frontal misalignment of more than 5 degrees and five of 16 (32 %) leg length discrepancy of more than 2cm. No misalignment or leg length discrepancy (>2cm) was observed among the five patients treated with a blade-plate. DISCUSSION: The results observed in our patients treated with the classical fixation systems are comparable with those reported by others. Our patients treated with the blade-plate system constitute the only series with no cases of frontal misalignment or invalidating leg length discrepancy after this type of fracture. We used contralateral distal femoral epiphysiodesis in all patients whose predictable leg length discrepancy at the end of growth was greater than 2cm, that is 11-3.5 years (bone age) in girls and 13-14.5 years in boys. CONCLUSION: Internal fixation techniques bridging the growth cartilage are the only techniques used for Salter and Harris type-II distal femoral physeal fracture-separation in adolescents which have been able to prevent posttraumatic knee misalignment (genu valgum or genu varum). Leg length discrepancy can be prevented by a contalateral distal femoral epiphysiodesis when the fracture occurs in a child or early puberty.

[Melorheostosis and anterior cruciate ligament tear in a 15-year-old female]. / Mélorhéostose et entorse du ligament croisé antérieur chez une jeune fille de 15 ans.

We report the case of a 15-year-old girl who suffered an indirect knee trauma. The standard X-rays revealed a tract of ivory-like bone partially obstructing the medullary canal of the femur and the tibia. Magnetic resonance imaging produced a hypointense signal on the T1 and T2 sequences. The radiographic diagnosis was melorheostosis which was confirmed on the biopsy specimen which ruled out other diagnoses. The MRI also revealed a tear of the anterior cruciate ligament, treated conservatively. Clinical and radiological surveillance were proposed for the melorheostosis.

[Progressive correction of the hand in the congenital radial clubhand]. / Centralisation progressive de la main dans la main bote radiale congénitale.

The therapeutic objective of a congenital radial clubhand is to obtain, at the end of the growth, a functional hand, that is a hand with a thumb, in the axis of the forearm with the most cosmetic aspect as possible. The challenge lies in the fact that the hand is not in the axis of the forearm. Thus, some authors realize a surgical centralization or radialization by doing a direct release of the retracted soft tissues. On the other hand, it is possible to correct the hand without any invasive surgery by using an external fixator allowing to correct the hand progressively. The Taylor Spatial Frame fixator is a system of external fixation which allows, by using a software, to realize this correction accurately.

Modelling interactions between farmer practices and fattening pig performances with an individual-based model.

European pig production continues to encounter economic and environmental challenges. To address these issues, methods have been developed to assess performances of pig production systems. Recent studies indicate that considering variability in performances among pigs improves the accuracy and reliability of results compared with modelling an average animal. Our objective was to develop a pig fattening unit model able to (i) simulate individual pig performances, including their variability in interaction with farmers' practices and management, and (ii) assess their effects on technical, economic and environmental performances. Farmer practices included in the model were chosen from a typology generated from on-farm surveys focused on batch management, pig allocation to pens, pig feeding practices, practices of shipping to the slaughterhouse, and management of the remaining pigs. Pigs are represented using an individual-based model adapted from the InraPorc® model. To illustrate the model's abilities, four scenarios were simulated that combine two feed rationing plans (ad libitum, restricted to 2.5 kg/day) and two feed sequence plans (two-phase, 10-phase). Analysis of variance was performed on the simulated technical, economic and environmental indicators (calculated via Life Cycle Assessment). The feed rationing plan and feed sequence plan significantly affected all indicators except for the premium per pig, for which the feed sequence plan did not have a significant effect. The 'restricted 10-phase' scenario maximised gross margin of the fattening unit (14.2 €/pig) and minimised environmental impacts per kg of pig produced. In contrast, the 'ad libitum two-phase' scenario generated the lowest margin (8.20 €/pig) and the highest environmental impacts. The model appears to be a promising tool to assess effects of farmers' practices, pig characteristics and farm infrastructure on technical, economic and environmental performances of the fattening unit, and to investigate the potential of improvement. However, further work is needed, based on virtual experiments, in order to evaluate the effects of a larger diversity of practices.

[Rituximab induced remission of pemphigus vulgaris: 2 cases]. / Pemphigus vulgaire évolutif sous corticoïdes et immunosuppresseurs: rémission sous rituximab. Deux observations.

INTRODUCTION: Pemphigus vulgaris frequently requires corticoids and immuno-suppressive drugs. The disease and the side effects of the drugs severely affect the quality of life, and sometime the vital prognosis of the patients. Other treatments than corticosteroids and immunosuppressive drugs are needed. EXEGESIS: We report 2 additional cases of pemphigus vulgaris uncontrolled by corticoids and immuno-suppressive drugs that responded spectacularly to rituximab. One patient had a recently onset disease, that was active despite 1,5 mg/kg/day prednisone and 1,5 g/day mycophenolate. She had a complete remission during 15 months after rituximab treatment. At relapse, another rituximab cycle led to a prompt remission. The other patient had longstanding pemphigus vulgaris complicated by cutaneous infections on prednisone (20 mg/d), immunosuppressive drugs and intravenous immune globulins. She had a prompt and complete remission after rituximab. CONCLUSION: Rituximab seems to be a promising drug for refractory pemphigus vulgaris. The benefit to risk ratio of this drug in this new indication must be precisely documented.

[Osteoid osteoma of the inferior articular process of L5 associated with a bilateral spondylosis: a case report]. / Ostéome ostéoïde de l'articulaire inférieure de L5 associé à une spondylolyse bilatérale: à propos d'un cas chez un enfant de 5 ans.

We report the case of an 8-year-old boy who presented an osteoid osteoma of L5 associated with bilateral spondylolysis involving the same vertebra. Diagnostic bone scintigraphy is highly contributive in children presenting back pain. For us, it is the first intention exploration in patients with isthmic lysis seen on the plain x-ray. Symptomatic spondylolysis is the most frequent cause of back pain in children and is much more frequent than vertebral osteoid osteoma. The presence of isthmic lysis associated with focal uptake on the bone scintigraphy is highly suggestive of symptomatic spondylolysis. In this context, magnetic resonance imaging should be performed for both diagnostic purposes and prognostic assessment. The degree of bone and soft tissue edema in the present case was unusual for symptomatic spondylolysis. Complementary computed tomography finally established the diagnosis of osteoid osteoma of the posterior vertebral arch. To our knowledge, the association of osteoid osteoma with bilateral spondylolysis on the same vertebra has not been described elsewhere. In children, the diagnosis of symptomatic spondylolysis can only be established after ruling out other causes of back pain. The diagnosis of osteoid osteoma must be kept in mind.

[A pediatric case of rupture of the brachial artery and radial nerve palsy secondary to proximal humeral exostosis]. / Rupture de l'artère brachiale et paralysie radiale secondaire à une exostose proximale de l'humérus chez une enfant de 14 ans.

Rupture of the brachial artery associated with radial nerve palsy in a context of exostosis of the proximal humerus has not been described to date in the literature. Our patient was a fourteen-year-old girl with a history of violent pain occurring suddenly with no prodrome or triggering factor. The pain was localized at the level of the proximal left humerus. Physical examination revealed the presence of a hematoma and complete motor radial nerve palsy. The diagnosis was not confirmed by computed tomography with contrast injection but was confirmed by magnetic resonance imaging which eliminated malignant transformation of the exostosis. After checking the neurovascular bundles and evacuating the hematoma, treatment consisted in resection of the exostosis and arterial repair with an autologous venous graft. We discuss the diagnostic and therapeutic challenges which present vascular complications due to exostosis.

[Fracture of the intercondylar eminence of the tibia type II in children: 20 surgically-treated cases]. / Fracture de l'éminence intercondylienne du tibia de type II chez l'enfant: à propos de 20 cas traités chirurgicalement.

PURPOSE OF THE STUDY: The purpose of this study was to detail therapeutic indications for fractures of the intercondylar eminence of the tibia with little displacement and preservation of the posterior hinge (type II fracture in the Zarincznyj classification). MATERIAL AND METHODS: We reviewed retrospectively a multicentric serie of type II fractures of the intercondylar eminence observed in children treated surgically. There were twenty patients, ten girls and ten boys, mean age 11.9 years (range 6-16). Imaging included plain x-rays of the knee (anteroposterior and lateral views) in all patients as well as computed tomography (5 patients) and magnetic resonance imaging (1 patient). Surgical treatment was performed in all cases, on average six days after trauma (range 0-25). A medial parapatellar arthrotomy was used in all cases. A non-resorbable thread was used for fixation associated with an anchor in the last four cases. Clinical and radiological assessment was reviewed at mean 3.7 years follow-up. RESULTS: All children had resumed their sports activities at the same level as before the accident within 4.8 months on average. None of the children suffered from an unstable knee or functional impairment at last follow-up. The Lysholm score was 88.9 on average (range 70-100) at three months postoperative and 99.2 (range 89-100) at last follow-up. DISCUSSION: There is currently agreement that non-displaced fractures of the anterior intercondylar eminence of the tibia should be treated orthopedically and that forms with displacement require surgery. Conversely, the type II fractures with an anterior gap but a preserved posterior hinge, the appropriate treatment remains a subject of debate. In our experience, surgery would appear to be preferable to orthopedic management. Surgery enables putting correct tension on the anterior crucicate ligament and limits the risk of residual laxity which, even though rarely associated with instability, could in the long-term lead to osteoathritic degradation or meniscal damage. CONCLUSION: Surgical treatment of fractures of the intercondylar eminence of the tibia with little displacement and preservation of the posterior hinge provides satisfactory results and the best guarantee of long-term stability.

Evaluation of the external fixator TrueLok Hexapod System for tibial deformity correction in children.

BACKGROUND: Tibial deformities are common in paediatric orthopaedic practice. Correcting multiplanar tibial deformities associated with lower limb length discrepancy can be challenging. Hexapod external fixation with gradual correction has been proven effective in this situation. OBJECTIVE: To assess clinical and radiological outcomes of gradual tibial deformity correction using the external fixator TL-HEX™ (Orthofix) in children. HYPOTHESIS: TL-HEX™ is effective in correcting tibial deformities in children. PATIENTS AND METHODS: This multicentre retrospective study collected data from the medical files of 26 patients with 31 tibial deformities treated by gradual correction using TL-HEX™. The tibial deformities were due to congenital defects in 11 (35%) cases, Blount's disease in 9 (29%) cases, pseudo-achondroplasia in 4 (13%) cases, and other causes in 7 (23%) cases. Mean age at surgery was 11.9 years. In each patient, antero-posterior long leg radiographs obtained pre-operatively and at last follow-up were used to measure parameters including the mechanical axis deviation (MAD), medial proximal tibia angle (MPTA), and leg length discrepancy (LLD). RESULTS: The mean healing index was 39.3 days/cm (range, 32-58 days/cm). The overall complication rate was 61%, with 11 unplanned visits. Superficial pin tract infection was the most common complication. Significant decreases between the pre-operative and post-operative assessments occurred in mean MAD (from 32.1mm to 10.2mm, P<0.001) and mean LLD (from 36.8mm to 9.1mm, P<0.001). Patients who underwent proximal tibial osteotomy had a significant improvement in MPTA, from 80.6° to 88.5° (P=0.006). DISCUSSION: This is the first clinical study specifically designed to assess outcomes of TL-HEX™ limb lengthening and deformity correction. MAD, MPTA, and LLD were significantly improved at last follow-up. MAD was greater than 10mm at last follow-up in only 11patients. The complication rate was similar to those reported with other external fixators. TL-HEX™ is effective in the management of tibial deformities in children. LEVEL OF EVIDENCE: IV (retrospective study).

Correction of axial deformity during lengthening in fibular hypoplasia: Hexapodal versus monorail external fixation.

INTRODUCTION: Childhood fibular hypoplasia is a rare pathology which may or may not involve limb-length discrepancy and axial deformity in one or more dimensions. The objective of the present study was to compare the quality of the axial correction achieved in lengthening procedures by hexapodal versus monorail external fixators. The hypothesis was that the hexapodal fixator provides more precise correction. MATERIAL AND METHODS: A retrospective multicenter study included 52 children with fibular hypoplasia. Seventy-two tibias were analyzed, in 2 groups: 52 using a hexapodal fixator, and 20 using a monorail fixator. Mean age was 10.2 years. Mean lengthening was 5.7cm. Deformities were analyzed and measured in 3 dimensions and classified in 4 preoperative types and 4 post-lengthening types according to residual deformity. RESULTS: Complete correction was achieved in 26 tibias in the hexapodal group (50%) and 2 tibias in the monorail group (10%). Mean post-correction mechanical axis deviation was smaller in the hexapodal group: 12.83mm, versus 14.29mm in the monorail group. Mean post-correction mechanical lateral distal femoral angle was 87.5° in the hexapodal group, versus 84.3° in the monorail group (P=0.002), and mean mechanical medial proximal tibial angle 86.9° versus 89.5°, respectively (P=0.015). DISCUSSION: No previous studies focused on this congenital pathology in lengthening and axial correction programs for childhood lower-limb deformity. The present study found the hexapodal fixator to be more effective in conserving or restoring mechanical axes during progressive bone lengthening for fibular hypoplasia. CONCLUSION: The hexapodal fixator met the requirements of limb-length equalization in childhood congenital lower-limb hypoplasia, providing better axial correction than the monorail fixator. LEVEL OF EVIDENCE: IV.