Efficacy of the pridie drilling technique in knee osteochondritis dissecans among children and young adults: follow-up of 41 cases.

PURPOSE: This study aims to examine whether Pridie drilling, a form of bone marrow stimulation, can expedite the healing process and enable a faster return to sports activity in patients with knee Osteochondritis dissecans (OCD). The primary objective is to assess the effectiveness of Pridie drilling in stable OCD lesions that do not respond to non-operative treatment, by evaluating the absence of painful symptoms 6 months after the procedure. Secondary objectives include evaluating radiographic reconstruction 6 months post-surgery and determining the time it takes to resume sports participation. MATERIALS AND METHODS: This single-center retrospective study included all cases of stable OCD in the knee that underwent anterograde chondral drilling between 2008 and 2020. Diagnosis of OCD was established using knee radiographs, and the surgical technique involved multiple multidirectional subchondral drilling. Treatment efficacy was defined by the absence of painful symptoms for 6 months postoperatively. RESULTS: A total of 41 knees were included in the study, and no complications were observed before or after surgery. At 6 months postoperatively, 32 knees (78%) showed complete resolution of symptoms. Complete radiographic reconstruction was observed in 66% of cases. Asymptomatic patients at 6 months returned to sports activity of similar intensity to that practiced previously in an average time of 7.9 months; while, patients who were symptomatic at 6 months returned in an average time of 16.5 months. CONCLUSION: This study provides evidence supporting the short-term efficacy of anterograde chondral drilling in stable lesion of OCD in children and adolescents after failed functional treatment. LEVEL OF EVIDENCE: Level III (retrospective cohort study).

Influence of the thoracolumbar junction flexibility on the risk of adding-on after posterior vertebral arthrodesis for thoracic idiopathic adolescent scoliosis.

PURPOSE: The objective was to analyze the role of the thoracolumbar sagittal flexibility on the outcome after posterior spinal fusion of Lenke 1 and 2 adolescent idiopathic scoliosis with last touched vertebra as the lowest instrumented vertebra. METHODS: We included 105 thoracic AIS patients who had a posterior spinal fusion with a 2 years minimum follow-up. Thoracolumbar junction flexibility was assessed on dynamic sagittal X-rays and compared to the standing position. Adding-on was defined according to radiographic Wang criteria. The junction was considered flexible if the variability from the static position to flexion and/or extension was greater than 10°. RESULTS: Mean age of the patients was 14 ± 2 years. The preoperative mean Cobb angle was 61 ± 12.7° and 27.5 ± 7.7° after surgery. Mean follow-up was 3.1 years. Twenty-nine patients (28%) developed an adding-on. Thoracolumbar junction range of motion was higher (p = 0.017) with higher flexibility in flexion (p < 0.001) in the no adding-on group. In no adding-on group, 53 patients (70%) had a flexible thoracolumbar junction, and 23 patients (30%) had a stiff thoracolumbar junction in flexion and flexible in extension. In adding-on group, 27 patients (93%) had a stiff thoracolumbar junction, and 2 patients (7%) had a flexible junction in flexion and stiff in extension. CONCLUSION: The flexibility of the thoracolumbar junction is a determining factor in the surgical outcome after posterior spinal fusion for AIS and should be considered in correlation with the frontal and sagittal alignment of the spine.

Efficacy of polyester bands placed under the transverse vertebral process for the correction of adolescent idiopathic scoliosis : A case series of 105 patients with a minimum of 24 months follow-up.

PURPOSE: To report an original technique for the surgical correction of adolescent idiopathic scoliosis (AIS) based on hybrid construct using polyester bands placed under the thoracic transverse processes. METHODS: We reviewed 105 patients operated between 2013 to 2017 for AIS with a minimum of 2 years follow-up. Clinical and radiological data, including 2D measurements of scoliosis parameters preoperatively, and at 3- and 24-months postoperatively were analyzed. Radiological analysis was performed by two independent observers using KEOPS (Smaio, Lyon-France, CE 2014) database. RESULTS: Mean age was 14.6 ± 2 years. Mean follow-up was 23.7 ± 1.2 months. Most curves were classified as Lenke-1 (78%). The average number of vertebra involved in the construct was 10.9 ± 1.3 (range 7-13). A mean of 12.8 implants were used per construct (mean implant density 0.59). The number of subtransverse bands placed averaged 3 (range 1-5 bands). The mean frontal Cobb angle decreased from 57.9 to 21.2 ° (p < 0.05) postoperatively. The average T4-T12 kyphosis increased from 20.2°to 32.4° (p < 0.05) postoperatively and no loss of correction was observed at 2 years follow-up. We encountered one case of transverse process fracture intraoperativley. No neurological complications were observed. In the postoperative period, 4 cases were diagnosed with distal junctional failure, three of which required an extension of the construct, while the fourth case was treated by bracing. CONCLUSIONS: The use of subtransverse band is an efficient and safe method for the surgical correction of AIS. This technique incorporates technical ease (minimal risk of neurological injury), provides good frontal correction and restores thoracic kyphosis. Results are maintained over a two-year period.

Multidisciplinary surgical strategy for dumbbell neuroblastoma: A single-center experience of 32 cases.

INTRODUCTION: Prognosis of dumbbell neuroblastoma (NBL) is mainly determined by the sequelae induced by the tumor itself and the neurosurgical approach. However, after primary chemotherapy, surgical management of the residual tumor, especially the spinal canal component, remains controversial. METHODS: We conducted a single-center retrospective cohort study over the last 15 years (2002-2017) including patients treated for NBL with spinal canal extension focusing on timing and type of surgery, complications, and functional and oncological follow-up. RESULTS: Thirty-two children (14 M, 18 F) were managed for NBL, with the majority (26) presenting with NBL stroma poor while four had ganglioneuroblastoma intermixed, one nodular, and one ganglioneuroma. All but two patients received neoadjuvant chemotherapy. Upfront laminotomy for spinal cord decompression was performed in two patients; nine patients had extraspinal surgery with a follow-up neurosurgical procedure in seven cases; eight patients had initial neurosurgery followed by an extraspinal procedure, while six patients underwent a combined multidisciplinary approach. With a median follow up of 3.6 years (0.1-14.9), 29 patients (90.6) are alive and two out of three (19, 65.5%) have functional sequelae. CONCLUSION: Patients with NBL with persistent spinal canal extension of the tumor after neoadjuvant chemotherapy treated at our center had outcomes that compare favorably with the literature. This is likely due to the multidisciplinary approach to optimal surgical strategy and continuous evaluation of the respective risks of tumor progression. Neurological disability results from initial spinal cord compression or the radicular sacrifice required for tumor resection.

The prevalence of lumbar spondylolysis in young children: a retrospective analysis using CT.

PURPOSE: Although lumbar spondylolysis is encountered in general population with an incidence estimated to be 3-10%, limited information is available for children. The aim of the study is to determine the prevalence of spondylolysis according to associated vertebral bony malformation and spinopelvic parameters in children under eight requiring CT evaluation for unrelated lumbar conditions. METHODS: Seven hundred and seventeen abdominal and pelvic multi-detector CT scans were obtained in patients under 8 years of age were reviewed. Two board certificated radiologists and two resident radiologists retrospectively evaluated CT scans for lumbar spondylolysis and associated malformations. Pelvic incidence and spondylolisthesis were reported. RESULTS: Our analysis included 717 CT scans in 532 children (259 girls and 273 boys). Twenty-five cases of spondylolysis were diagnosed (16 bilateral and 9 unilateral, 64 and 36%, respectively) in 14 boys (56%) and 11 girls (44%), associating with 12 grade I spondylolisthesis. The mean normal pelvic incidence was 45° (median 44°, SD 7°). The prevalence of spondylolysis was 1% in children under age 3 (n = 3 among 292 patients), 3.7% in children under age 6 (n = 17 among 454 patients) and 4.7% among the 532 patients. Unilateral spondylolysis was significantly associated with a spinal malformation (p = 0.04, Fisher's exact test), with normal pelvic incidence. Half of the patients with bilateral spondylolysis had high pelvic incidence. CONCLUSIONS: We observed a prevalence peak of unilateral spondylolysis in the context of a specific malformation in young infants under age 4 with normal pelvic incidence, and, then, a progressive increase in the prevalence of bilateral isolated spondylolysis.

Proximal junctional kyphosis in thoracic adolescent idiopathic scoliosis: risk factors and compensatory mechanisms in a multicenter national cohort.

INTRODUCTION: Proximal junctional kyphosis (PJK) is a frequent complication, up to 46%, in adolescent idiopathic scoliosis surgical treatment (AIS). Several risk factors have been evoked but remain controversial. The purpose of this study was to analyze the incidence of PJK in a multicenter cohort of AIS patient and to determine risk factor for PJK. MATERIALS AND METHODS: Lenke I and II AIS patients operated between 2011 and 2015 (minimum of 2-years follow-up) were included. On fullspine X-rays, coronal and sagittal radiographic parameters were measured preoperatively, postoperatively and at final follow-up. Occurrence of radiological PJK corresponding to a 10° increase in the sagittal Cobb angle, measured between the upper instrumented vertebra (UIV) and UIV + 2, between postoperative and 2-years follow-up X-rays, was reported. RESULTS: Among the 365 patients included, 15.6% (n = 57) developed a PJK and only 10 patients required a revision surgery. Preoperatively, PJK patients had significantly larger pelvic incidence (57° ± 13° vs. 51° ± 12°), larger lumbar lordosis (LL) (63° ± 12° vs. 57° ± 11°) and bigger C7 slope. Postoperatively (3 months), in the non-PJK group, thoracic kyphosis (TK) was increased and LL was not significantly different. However, postoperatively, in the PJK group, no significant change was observed in TK, whereas C7 slope decreased and LL significantly increased. There was also a postoperative change in inflection point which was located at a more proximal level in the PJK group. Between postoperative time and final follow-up, TK and LL significantly increased in the PJK group. CONCLUSION: PJK is a frequent complication in thoracic AIS, occurring 16%, but remains often asymptomatic (less than 3% of revisions in the entire cohort). An interesting finding is that patients with high pelvic incidence and consequently large LL and TK were more at risk of PJK. As demonstrated in ASD, one of the causes of PJK might be postoperative posterior imbalance that can be due to increased LL, insufficient TK or inflection point shift during surgery. These slides can be retrieved under Electronic Supplementary Material.

Normal human adipose tissue functions and differentiation in patients with biallelic LPIN1 inactivating mutations.

Lipin-1 is a Mg2+-dependent phosphatidic acid phosphatase (PAP) that in mice is necessary for normal glycerolipid biosynthesis, controlling adipocyte metabolism, and adipogenic differentiation. Mice carrying inactivating mutations in the Lpin1 gene display the characteristic features of human familial lipodystrophy. Very little is known about the roles of lipin-1 in human adipocyte physiology. Apparently, fat distribution and weight is normal in humans carrying LPIN1 inactivating mutations, but a detailed analysis of adipose tissue appearance and functions in these patients has not been available so far. In this study, we performed a systematic histopathological, biochemical, and gene expression analysis of adipose tissue biopsies from human patients harboring LPIN1 biallelic inactivating mutations and affected by recurrent episodes of severe rhabdomyolysis. We also explored the adipogenic differentiation potential of human mesenchymal cell populations derived from lipin-1 defective patients. White adipose tissue from human LPIN1 mutant patients displayed a dramatic decrease in lipin-1 protein levels and PAP activity, with a concomitant moderate reduction of adipocyte size. Nevertheless, the adipose tissue develops without obvious histological signs of lipodystrophy and with normal qualitative composition of storage lipids. The increased expression of key adipogenic determinants such as SREBP1, PPARG, and PGC1A shows that specific compensatory phenomena can be activated in vivo in human adipocytes with deficiency of functional lipin-1.

Cobb-1 versus cobb-to-cobb anterior fusion for adolescent idiopathic scoliosis Lenke 5C curves: a radiological comparative study.

PURPOSE: Anterior fusion is a well-established procedure for the treatment of Lenke 5C adolescent idiopathic scoliosis (AIS). This retrospective study aimed to assess preoperative and postoperative radiographic differences between the conventional anterior fusion and anterior short fusions (ASF) in Lenke 5C AIS. METHODS: Radiographic data of 42 consecutive cases of Lenke 5C AIS, which were surgically treated through anterior segmental fusion, were analyzed retrospectively. Patients have been divided into two groups: C group (n = 19) treated by the conventional fusion from the proximal end vertebra to the distal end vertebra of the main curve and C-1 group (n = 23) treated by ASF, sparing the lowest end vertebra of the main curve. Cobb angles of main curve, apical vertebra tilt, C7 coronal tilt, lowest instrumented vertebra angle (LIV angle), LIV adjacent level disc angulation (LIVDA), and the first uninstrumented vertebra angle (FUV angle) were measured on anteroposterior radiographs of the entire spine. LIVDA, FUV wedging, and rotation were measured on stretch films. C7 sagittal tilt, lumbar lordosis, thoracic kyphosis, and proximal kyphosis junction were measured on lateral radiographs of the entire spine. Repeated-measures analysis of variance and fisher test were used for the statistical analysis. RESULTS: The preoperative main curve was 39.9 ± 9.1° in the C group vs. (versus) 42.8 ± 11.8° in the C-1 group. At a mean follow-up of 26.2 months (range 10.5-66.3 months), postoperative main curve improved of 75.8 ± 21.2 % (10.4 ± 9.2°, p < 0.001) in the C group and of 52.7 ± 18.7 % (20.1 ± 8.1°, p < 0.001) in the C-1 group. All parameters improved except the LIVDA, which was slightly impaired, especially in the C-1 group with 5.6 ± 4.2° vs. 4.4 ± 2.2° in the C group. On stretch films, FUV rotation was the only parameter to differ; it was graded at 1 ± 0.7 in the C-1 group vs. 0.6 ± 0.5 in the C group (p = 0.04). No disk obliquity just under the future instrumentation and equivalent FUV wedging were found in any of the two groups. CONCLUSIONS: The conventional anterior fusion and ASF give equivalent correction in Lenke 5C AIS, but ASF seems to induce adding-on of the disk below the LIV. FUV rotation on stretch films does not seem to be a predictive factor of postoperative radiological outcome.

Internal fixation with occipital hooks construct for occipito-cervical arthrodesis. Results in 14 young or small children.

PURPOSE: Evaluation of effectiveness of internal rigid fixation for occipito-cervical fusion with occipital hooks and cervical screws and/or hooks to improve fusion in young or small children with various bone dysplasia or congenital abnormality. METHODS: Fourteen children with mean age of 8.4 years and height and weight below 140 cm and 35 kg, respectively, who underwent occipito-cervical fusion for miscellaneous pathologies reading to stenosis and/or instability were reviewed. The posterior instrumentation consisted of a precontoured titanium plate rod with an occipital fixation by hooks and a vertebral fixation by screws and/or hooks. Eight patients had cervical fixation with C2 pedicle screws. The mean follow-up was 48 months (27-81 months). RESULTS: Thirteen patients (92.8 %) had a complete fusion and no failure of the fixation was observed. We had two deep wound infections not related to implants. CONCLUSION: Instrumentation was technically feasible even in a very young child. Rigid internal fixation in the little children did not increase surgical complications and significantly increased the union rate of occipito-cervical arthrodesis.

Animal models for scoliosis research: state of the art, current concepts and future perspective applications.

PURPOSE: The purpose of this study was to provide the readers with a reliable source of animal models currently being utilized to perform state-of-the-art scoliotic research. MATERIALS AND METHODS: A comprehensive search was undertaken to review all publications on animal models for the study of scoliosis within the database from 1946 to January 2011. RESULTS: The animal models have been grouped under specific headings reflecting the underlying pathophysiology behind the development of the spinal deformities produced in the animals: genetics, neuroendocrine, neuromuscular, external constraints, internal constraints with or without tissue injury, vertebral growth modulation and iatrogenic congenital malformations, in an attempt to organize and classify these multiple scoliotic animal models. As it stands, there are no animal models that mimic the human spinal anatomy with all its constraints and weaknesses, which puts it at risk of developing scoliosis. What we do have are a multitude of models, which produce spinal deformities that come close to the idiopathic scoliosis deformity. CONCLUSION: All these different animal models compel us to believe that the clinical phenotype of what we call idiopathic scoliosis may well be caused by a variety of different underlying pathologies.

Residual acetabular dysplasia in congenital hip dysplasia.

Residual hip dysplasia may exist despite appropriate treatment of congenital hip dysplasia (CHD). The abnormalities chiefly affect the acetabulum and can lead to premature osteoarthritis. Although the main cause is delayed treatment of CHD, primary lesions are also possible and may be worsened by the initial treatment itself. Residual hip dysplasia must be detected during the follow-up of patients with CHD. The antero-posterior radiograph of the pelvis is the main diagnostic tool. However, the importance of non-ossified anatomical structures requires additional investigations such as arthrography and magnetic resonance imaging. The risk of premature osteoarthritis is difficult to predict based only on the imaging-study findings. Hip dysplasia is best treated before 5 years of age. The work-up at this age should allow determination of the best treatment. Surgery is required but should not be performed unnecessarily. The decision rests on the absence of improvement in the radiographic criteria and on the findings from additional imaging studies. The usual treatment is Salter's osteotomy, during which excessive anterior displacement should be avoided. At adolescence, the information provided by radiography in the coronal plane should be completed by a three-dimensional evaluation of the acetabulum and an assessment of the quality of the labrum. The shelf procedure has been proven to relieve pain and to significantly postpone the need for hip arthroplasty, when performed early, before the development of visible osteoarthritis, and on a congruent hip. Chiari's osteotomy has a role to play in complex dysplasia affecting both the acetabulum and the femur. Periacetabular osteotomy is getting more used thanks to cooperation between paediatric and adult orthopaedic surgeons. This osteotomy provides optimal correction in all three dimensions.

Outcomes of 53 thoracic outlet syndrome cases with confirmed neurological deficit.

INTRODUCTION: Neurogenic thoracic outlet syndromes (TOS) are dominated by the nonspecific forms. This study focuses only on the rarer true forms related to proximal nerve compression in the thoracic outlet, with the presence of motor (atrophy of the hand's intrinsic muscles) and/or sensory (hypoesthesia in the territory of the medial antebrachial cutaneous nerve) deficits. The objectives of this study were to define the clinical characteristics, anatomical causes and surgical results of this condition. PATIENTS AND METHODS: Single-center retrospective study of 53 consecutive cases in 50 patients with an objective clinical deficit confirmed by nerve conduction studies. The population consisted of 47 adults and 3 children, 9 males and 41 females, with a mean age of 39 years (9-80 years), diagnosed between July 1994 and December 2019. An objective motor deficit was present in 50 cases, with the remaining 3 having a sensory deficit only. Forty cases underwent surgery, most often via the supraclavicular approach, while 13 cases did not undergo surgery because their deficit was longstanding and non-progressive. RESULTS: One operated patient was lost in follow-up. An analysis of the medical records of 18 cases, including 15 operated cases found complete recovery in 4 cases, significant improvement in 9 cases and small improvement in 2 cases at a mean follow-up of 53 months (1-162 months). Thirty-four cases were reviewed in person, including 24 operated cases and evaluated with a mean follow-up of 135 months (36-284 months): the pain had disappeared in 21 cases, thenar atrophy persisted in 17 cases, which was associated with a claw-hand deformity in 3 cases, while 2 cases had an isolated claw-hand deformity. The patients were very satisfied with the procedure in 15 cases and satisfied in 9 cases. They evaluated the benefit of surgery at 87% and their upper limb function increased from 38% (10-60%) preoperatively to 77% (60-100%) at the review. CONCLUSION: Few studies in the literature have focused on true neurogenic TOS cases. The treatment is surgical in progressive cases; an anatomical anomaly is always present. Surgical treatment eliminates the pain and helps to stabilize or even partially resolve the deficit. Despite a moderate objective gain, the patients' feeling of functional improvement is important with a high satisfaction rate. LEVEL OF EVIDENCE: IV, retrospective.

High-grade L5-S1 spondylolisthesis with lumbosacral kyphosis: Long-term results of non-instrumented circumferential arthrodesis in children, adolescents.

INTRODUCTION: The choice of surgical technique for high-grade spondylolisthesis (HGS) associated with lumbosacral kyphosis remains controversial. Are non-instrumented techniques still relevant, what with the multiplicity and modernity of patient-specific instrumentation? HYPOTHESIS: Our hypothesis was that a non-instrumented circumferential arthrodesis performed after a period of gradual reduction of HGS, associated with lumbosacral kyphosis, provided satisfactory long-term functional and radiographic results in children and adolescents while minimizing the risk of complications. MATERIALS AND METHODS: Thirty-one L5-S1 HGS associated with a lumbosacral kyphosis operated by non-instrumented circumferential arthrodesis after a period of traction and suspension were included in our study. The first stage of this technique consisted of a gradual reduction using traction followed by immobilization in the corrected position. The second stage involved a posterior, followed by an anterior, surgical procedure and a spica cast immobilization for 4 months. The mean age at surgery was 13.9±2.3 years (6-18) and the mean follow-up was 10.3±4.5 years (2.1-17.8). RESULTS: The overall complication rate was 26% (n=8/31): 13% neurologic complications, 10% bone fusion defects and 3% skin complications. The reoperation rate was 13% (n=4/31). The mean ODI (/50) was 3±4.6 (0-22) and the SRS-30 126.7±15 (72-143). The Taillard index decreased by 25% (p<.001) and remained stable throughout the follow-up period (p=.65). The lumbosacral angle was corrected by 13.5% (p=.03) and the correction was maintained throughout the follow-up period (p=.71). At the last follow-up, the lumbosacral angle was significantly correlated with a low ODI score and a high SRS-30 score (p<.05). CONCLUSION: Even though this technique achieved a smaller reduction of the lumbosacral angle, it reduced by at least a factor of three the incidence of neurologic complications and resulted in satisfactory functional outcomes when compared to instrumented and intraoperative correction series. LEVEL OF EVIDENCE: IV.

Petit-Morel method for hip development dysplasia in toddlers: A retrospective observational study in 34 patients.

BACKGROUND: The Petit-Morel method allows the treatment of developmental hip dysplasia in toddlers by combining gradual traction to achieve reduction followed by immobilisation during which pelvic osteotomy is performed. The objective of this study was to assess the radiographic and clinical outcomes in a retrospective cohort of patients. HYPOTHESIS: The Petit-Morel method is associated with low rates of avascular necrosis and residual acetabular dysplasia at skeletal maturity, as well as with satisfactory medium-term clinical outcomes. MATERIAL AND METHODS: We conducted a single-centre retrospective study of 34 patients (35 hips) treated between 1997 and 2014. The radiological assessment criteria included an evaluation for avascular necrosis classified according to Kalamchi and MacEwan, the vertical centre edge (VCE) angle, femoral head sphericity according to Mose, and acetabular dysplasia at skeletal maturity according to Severin. Hip function was assessed by determining the Postel-Merle d'Aubigné (PMA) score. RESULTS: Mean age at treatment was 19±4 months (range, 14-29). Mean follow-up was 11 years (range, 5-20). There were two failures including one case of recurrent dislocation requiring surgical reduction. Group II avascular necrosis occurred in 1 (3%) patient. Tönnis Grade IV dysplasia was significantly associated with resolving irregularity of the ossification centre, seen in 19 (54%) cases (p=0.002). In the 18 patients followed-up to skeletal maturity, with a mean follow-up of 15 years (range, 12-20 years), 17 hips were Severin Class I. The mean VCE angle was 29° (range, 15°-38°), and the head was spherical for 34 (98%) hips. The PMA score at last follow-up was excellent (17-18). The mean VCE angle was greater in all 5 patients who experienced pain during long walks (35° [range, 32°-37°]) than in the asymptomatic patients (28° [range, 15°-38°]) (p=0.009). DISCUSSION: The Petit-Morel method is a reliable treatment that provides good clinical and radiological outcomes. Overcorrection of the VCE angle was noted in the patients who experienced walking-related pain in adulthood. LEVEL OF EVIDENCE: IV, retrospective observational cohort study.

Surgical outcomes of spinal osteochondroma in children: A multicentre observational study.

BACKGROUND: Spinal osteochondroma (or exostosis) is a rare benign tumour whose clinical manifestations are delayed due to their slow growth and location. Few studies have addressed the characteristics and the diagnostic and therapeutic peculiarities of spinal osteochondroma in children. The objective of this multicentre observational study was to assess the outcomes of a cohort of children after surgery for spinal osteochondroma. HYPOTHESIS: Surgical excision of spinal osteochondroma in children is not followed by complications or recurrences. MATERIAL AND METHODS: We included consecutive children who had surgery between 2010 and 2018 at any of eight participating centres to remove spinal osteochondromas. The cause, clinical manifestations, and location of the lesions were collected. The surgical outcomes were evaluated after at least 2 years' follow-up. RESULTS: We identified 22 patients who had surgery to remove 26 spinal osteochondromas at a mean age of 12.8±2.6 years. Among them, 7 had a solitary osteochondroma (SO group) and 15 had hereditary multiple osteochondromas (HMO group). At diagnosis, 72% of patients had clinical signs (spinal pain, n=4; one or more lumps, n=5; and neurological manifestations, n=3). In the HMO group, the diagnosis was made during routine MRI screening for tumours involving the spinal canal. Most osteochondromas involved the cervical spine (n=13), with no difference between the two groups (p=0.9). The lamina was the most common location but 54% of the tumours were growing within the canal (92% in the HMO group). After a mean follow-up of 5.2±4.4 years, no patients had experienced any recurrences or complications related to the disease or treatment. DISCUSSION: Surgical excision of spinal osteochondromas in children is effective, with no medium-term recurrences. Our results also confirm the low peri-operative morbidity, even when the canal is involved, and the absence of any effect at last follow-up on spinal alignment. All patients with neurological manifestations at diagnosis made a full recovery. LEVEL OF EVIDENCE: IV, retrospective observational cohort study.

The reliability of the AOSpine Thoracolumbar Spine Injury Classification System in children: an international validation study.

PURPOSE: To evaluate the AOSpine Thoracolumbar Spine Injury Classification System and if it is reliable and reproducible when applied to the paediatric population globally. METHODS: A total of 12 paediatric orthopaedic surgeons were asked to review MRI and CT imaging of 25 paediatric patients with thoracolumbar spine traumatic injuries, in order to determine the classification of the lesions observed. The evaluators classified injuries into primary categories: A, B and C. Interobserver reliability was assessed for the initial reading by Fleiss's kappa coefficient (kF) along with 95% confidence intervals (CI). For A and B type injuries, sub-classification was conducted including A0-A4 and B1-B2 subtypes. Interobserver reliability across subclasses was assessed using Krippendorff's alpha (αk) along with bootstrapped 95% CIs. A second round of classification was performed one-month later. Intraobserver reproducibility was assessed for the primary classifications using Fleiss's kappa and sub-classification reproducibility was assessed by Krippendorff's alpha (αk) along with 95% CIs. RESULTS: In total, 25 cases were read for a total of 300 initial and 300 repeated evaluations. Adjusted interobserver reliability was almost perfect (kF = 0.74; 95% CI 0.71 to 0.78) across all observers. Sub-classification reliability was substantial (αk= 0.67; 95% CI 0.51 to 0.81), Adjusted intraobserver reproducibility was almost perfect (kF = 0.91; 95% CI 0.83 to 0.99) for both primary classifications and for sub-classifications (αk = 0.88; 95% CI 0.83 to 0.93). CONCLUSION: The inter- and intraobserver reliability for the AOSpine Thoracolumbar Spine Injury Classification System was high amongst paediatric orthopaedic surgeons. The AOSpine Thoracolumbar Spine Injury Classification System is a promising option as a uniform fracture classification in children. LEVEL OF EVIDENCE: III.

Thrombotic risk in children undergoing orthopedic surgery.

Children are physiologically protected against venous thromboembolism (VTE). Specific triggering events or contributing factors have been identified in the majority of reported cases, which differs from the adult pathology where 50% of the thromboses are considered "idiopathic". This is a rare disease in children with an estimated frequency of less than 1/1000. The risk is highest in neonates, then decreases and increases again around 13 years to reach the same level as adults at 16 years. The risk of VTE is clearly higher in certain situations: significant trauma, prolonged immobilization, central venous catheter, stay in intensive care unit, inherited thrombophilia, cancer, obesity, oral contraceptives, etc. Thromboprophylaxis should not be used systematically, even in adolescents. Proper hydration and early mobilization form the basis of mechanical thromboprophylaxis. A prescription is only given after careful analysis of the child's risk factors and the orthopedic context. Thrombotic risk assessment scores - which are based on expert opinion and large VTE registers but have not been evaluated in clinical studies - are currently the most reliable method to evaluate the thrombotic risk in children and to prescribe thromboprophylaxis. Low-molecular weight heparin are the most commonly used thromboprophylaxis agents in children, with good tolerance and efficacy.

Epidemiology of spinal fractures in children: Cross-sectional study.

INTRODUCTION: Epidemiological studies of fractures of the spine in children are all old, mostly single-centre, with series spanning periods of 5 to 20 years. HYPOTHESIS: As lifestyle is constantly changing, notably with an increase in sports activities and improvements in the prevention of road and household accidents, epidemiology has likely changed. OBJECTIVE: To update the description of spinal trauma in children and adolescents compared to the existing literature. MATERIAL AND METHOD: A multicentre cross-sectional study of spinal fracture, dislocation and spinal cord injury without radiological abnormality (SCIWORA) in children was carried out in 15 French university hospital centres, for a period of one year (2016). RESULTS: One hundred and sixty-five children were identified: 85 girls, 80 boys; mean age 11 years (range, 10 months-17 years); median, 12 years 6 months. One hundred and fifty-two children (92%) had fracture, 8 (5%) dislocation (including 7 C1-C2 rotary dislocations), and 5 (3%) SCIWORA. Fractures were multiple in 80 cases (49%), contiguous in 73 cases (91%) and non-contiguous in 7 (9%). Locations were cervical in 25 cases (15%), thoracic in 85 (52%), lumbar in 75 and sacral in 4 (2%). Fracture types comprised 234 vertebral compactions (78%), 25 burst fractures (8%), 5 chance fractures (2%), 2 odontoid fractures, and 33 other lesions. Causes comprised fall in 77 cases (47%), sports accidents in 56 (34%), road accidents in 29 (18%), and others in 3. In 52 cases (32%), there was ≥1 associated lesion: appendicular in 35 cases (67%), thoracic or abdominal in 31 (60%), and head in 16 (31%). Twenty-one cases had multiple lesions (40%). Eighteen cases showed neurological involvement (11%) including 5 SCIWORAs. Neurological complications were more frequent before 9 years of age. CONCLUSION: The epidemiology of spine fractures in children has slightly changed. There are now fewer cervical lesions. Causes are less often road accidents and more often sports accidents. Multi-level lesions remain frequent and the rate of neurological complications is around 10%. Compaction fracture is the most common type.

Influence of asymmetric tether on the macroscopic permeability of the vertebral end plate.

We implemented an experimental model of asymmetrical compression loading of the vertebral end plate (VEP) in vivo. The macroscopic permeability of the VEP was measured. We hypothesized that static asymmetrical loading on vertebrae altered the macroscopic permeability of the VEP. In scoliosis, solute transport to and from the disc is dramatically decreased especially at the apical intervertebral disc. The decrease in permeability could be induced by mechanical stress. Nine skeletally immature pigs were instrumented with left pedicle screws and compression rod at the T5/T6 and L1/L2 levels. After 3 months, three cylindrical specimens of the VEP were obtained from each of the tethered levels. A previously validated method for measuring permeability, based on the relaxation pressure due to a transient-flow rate was used. A pistoning device generated a fluid flow that fully saturated the cylindrical specimen. The decrease in upstream pressure was measured using a pressure transducer, which allowed the macroscopic permeability to be derived. A microscopic study completed the approach. Overall macroscopic permeability was lower for the tethered VEPs than for the VEPs of the control group, respectively -47% for flow-in (p = 0.0001) and -46% for flow-out (p = 0.0001). In the tethered group, macroscopic permeability of the specimens from the tethered side was lower than macroscopic permeability of those from the non-tethered side, -39% for flow-out (p = 0.024) and -47% for flow-in (p = 0.13). In the control group, the macroscopic permeability was greater in the center of the VEP than in its lateral parts for flow-out (p = 0.004). Macroscopic permeability of the center of the VEPs was greater for flow-out than for flow-in (p = 0.02). There was no significant difference between thoracic and lumbar. This study demonstrated that compression loading applied to a growing spine results in decreased permeability of the VEP. This result could be explained by local remodeling, such as calcification of the cartilage end plate or sclerosis of the underlying bone.

Results and complications of a surgical technique for correction of coxa vara in children with osteopenic bones.

BACKGROUND: Surgical correction of coxa vara in children with osteopenic bone diseases could be very challenging. In this study, we describe a modified surgical technique for the correction of coxa vara in children with bone fragility. We also report the results and complications of this technique in 16 children (21 coxa vara) with osteopenic bone diseases. METHODS: Charts, clinic notes, and radiology images of 16 patients (21 hips) who had a proximal femoral osteotomy for the treatment of coxa vara in osteogenesis imperfecta (18 hips) and fibrous dysplasia (3 hips) in our institution between 1996 and 2005 were reviewed. The modified surgery involved an intertrochanteric osteotomy and the use of Kirshner wires and intramedullary rods. Neck-shaft angle, Hilgenreiner-epiphyseal angle, and head-shaft angle were assessed at preoperative, postoperative, and final follow-up. RESULTS: The average age at surgery was 8.3 years (range, 3.3-15.8 years). The average correction of the neck-shaft angle was from 84.6 to 114.4 degrees, and for the Hilgenreiner-epiphyseal angle, it was from 67.7 to 42 degrees at final follow-up. All osteotomies were healed at 3 months postoperatively. The mean follow-up was 4.29 years (range, 1.70-8.12 years). The average improvement in abduction and external rotation of the hips was 14 and 15 degrees, respectively. There were no cases of infection and 2 cases (12%) of implant-related complications. One patient with fibrous dysplasia needed replacement of the intramedullary rod and additional distal femoral osteotomy 1 week postsurgery. In another patient, the intramedullary rod had migrated proximally, which was corrected 5 months postsurgery by advancing the rod distally. CONCLUSION: Results suggest that this surgical technique provides satisfactory correction of coxa vara in children with osteopenic bone diseases. CLINICAL RELEVANCE: The described surgical technique used to correct coxa vara is reproducible and safe and has few complications. Furthermore, the size of the implants used allows surgery to be performed in very young children.