Juvenile hallux valgus: Comparison of three types of osteotomy and medium-term postoperative results.

BACKGROUND: There is no consensus on the treatment of juvenile hallux valgus (JHV). Numerous surgical techniques have been described, none of which has been proven to be superior and the mid-term results of these methods are not well known. Our objective was to compare the mid-term clinical, radiographic, and functional results of three metatarsal osteotomy techniques. METHODS: Patients under 18 years of age operated on for JHV between January 2010 and December 2019 were included in this multicenter retrospective study. Patients were excluded if they had non-idiopathic hallux valgus or if their postoperative follow-up was less than 3 years. The surgical techniques used were metatarsal osteotomies: basimetatarsal, scarf, or distal. During follow-up visits, we collected HMIS-AOFAS (Hallux Metatarsophalangeal Interphalangeal Scale-American Orthopedic Foot and Ankle Society) and Visual Analogue Scale (VAS) scores, acquired radiographs, and recorded complications and recurrences. Secondarily, the study population was stratified according to physis status (open vs. closed). RESULTS: During the study period, 18 patients (26 feet) met the inclusion criteria. The median postoperative follow-up was 6.5 (4.1) years. At the end of follow-up, the median HMIS score was 79.0 (20.0), the mean hallux valgus angle (HVA) improvement was 13.2° (16.8), and the complication and recurrence rates were 31 % and 23 %, respectively. There was no significant difference in the outcome measures between the three techniques or any difference according to physis status at the time of surgery. DISCUSSION AND CONCLUSION: The functional and radiographic results of metatarsal osteotomies are good in the medium term, regardless of the osteotomy site. Our results are comparable to those published in the literature. As our sample size was limited, it did not lead to the identification of statistically significant differences.

Tibia Valga Correction by Extraperiosteal Fibular Release in Multiple Exostosis Disease.

Genu valgum is a frequent deformity encountered in Multiple Hereditary Exostosis (MHE) patients. If left untreated, lower limb deformity leads to poor functional outcomes in adulthood. Our hypothesis was that in some cases, fibular shortening would lead to a lateral epiphysiodesis-like effect on the tibia. We herein report the case of a 6-year-old child with MHE who underwent extraperiosteal resection of the fibula for tibia valga correction. To obtain the lateral release of the calf skeleton, resection included inter-tibio-fibular exostosis along with proximal fibular metaphysis and diaphysis without any osseous procedure on the tibia. Gradual improvement of the valgus deformity occurred during follow-up (HKA from 165° preop to 178° at 27-month follow-up). Lateral release of the fibula led to an increase in the fibula/tibia index (from 93% preop to 96% at follow-up). Studying fibular growth in MHE patients could help understand how valgus deformity occurs in these patients. Even if encouraging, this result is just the report of a unique case. Further research and a larger series of patients are required to assess fibular release as a valuable option to treat valgus deformity in MHE.

Athletic children: Guidelines and monitoring in pediatric orthopedic surgery.

In day-to-day practice pediatric orthopedic surgeons often come up against the question of sport. The aim of the present study was to analyze the relationship between sport and childhood, with 3 questions: (1) What are the benefits of sport for children? (2) How to manage high-level child athletes? And (3) What sports are possible after major orthopedic surgery? Sports provide many benefits for children, and are to be encouraged. Sixty minutes' moderate to intense physical activity per day benefits motor development and bone mineralization and reduces the risk of obesity. On the other hand, excessive sports activity, as encountered in high-level sport, can be harmful for the child's development. The amount of training should not exceed a certain threshold in terms of hours per week according to age. Surgical treatment of sport-related traumatic lesions does not necessarily accelerate return to sport: indications need to be reasonable, despite pressure from the patient's circle. Sports are possible after major orthopedic surgery, although return to sport tends to be delayed and the level is lower than preoperatively.

Treatment of knee sprains in children.

The incidence of knee sprains in children is steadily increasing. Skeletal immaturity and anatomical features of the child's ligamentous structures explain the frequency of bone avulsions in young children. Peripheral ligament injuries are the most common and often benign. Nevertheless, associated injuries of the cruciate or patellofemoral ligament(s) are not rare and must not be missed. Age is a determining factor in diagnostic guidance. Anterior intercondylar tibial eminence fractures, otherwise known as tibial spine fractures (TSF), usually occur in young children. Ligamentous distension at the time of the accident would explain the residual laxity that can affect the prognosis of these fractures. The treatment of interstitial ruptures of the ACL follows recommendations that are becoming clearer through multicentric studies. Reparation techniques, historically rejected as ineffective, have again become topical under specific conditions with the aim of preserving the native ACL and its proprioceptive receptors, which are essential in children. ACL reconstruction techniques have made progress in children, especially with techniques adapted from adults. Preservation of growth plates remains pertinent, especially at the femur to avoid growth disorders, thus highlighting the important role paediatric orthopaedic surgeons have in the management of these knee sprains.

Can the TrueLok Hexapod System™ be used to accurately correct lower limb deformity in children?

INTRODUCTION: Progressive bone lengthening in children can be done using an external fixator, a lengthening nail, or plate with screws. The TrueLok Hexapod System™ (TL-HEX™) is the newest hexapod external fixator on the market. We hypothesized that the TL-HEX™ can accurately correct lower limb deformities in children. The goal of this study was to evaluate the clinical and radiographic outcomes after correcting lower limb deformities in children using the TL-HEX™ system. MATERIAL AND METHODS: Data from 58 limbs that underwent bone lengthening with the TL-HEX™ were analyzed for this retrospective, single-center study. The average patient age was 11.4 years. The femur was lengthened in 23 limbs and the tibia in 35. The outcomes were evaluated using long leg standing radiographs preoperatively and at the final assessment. The variables of interest were the mechanical axis deviation (MAD), mechanical lateral distal femoral angle (mLDFA), mechanical lateral proximal tibia angle (mMPTA), healing index (HI) and accuracy of the correction. The complications were graded on a 4-point scale summarizing three broad goals: planned correction, duration of treatment and sequelae. The accuracy of the correction was defined as the difference between the planned correction and the actual correction achieved. RESULTS: The mean HI was 37 days/cm. Significant correction was achieved for leg length discrepancy (LLD) (60 mm vs. 20 mm; p<0.01) and mLDFA (88.6° vs. 89.9°; p=0.04) but not the MAD (17.7 vs. 14.7; p= 0.17) or mMPTA (87.3 vs. 88.1; p=0.08). In the entire cohort, the difference from planned was 12.5 mm (p<0.01) for lengthening, 1.3° for the mLDFA (p=0.5) and 3° for the mMPTA (p=0.02). Relative to the initial goal, the mean lengthening achieved was 118%. In the sub-group where the plan did not need to be modified, the accuracy of the correction was better. There were 40 complications (69%). CONCLUSION: The TL-HEX™ is an effective and accurate system. The complication rate associated with its use is the same as other hexapod external fixators. Surgeons and patients must be aware of the high complication rate, which may require the plan to be modified and could potentially compromise the outcome.

Pelvic fractures in children (pelvic ring and acetabulum).

Pelvic fractures in children are rare and often the result of high-energy trauma. The possibility of associated lesions cannot be ignored. Treatment at a specialized children's hospital is a must. The multidisciplinary care team must include a paediatric orthopaedic surgeon. In the emergency room, the surgeon contributes to haemodynamic stabilization of the child by reducing and stabilizing posterior arch fractures and restoring the skeletal cohesion to make it easier to move the child and allow other examinations to be performed. Imaging modalities are used to determine the stability of the pelvic ring fracture, the risk of epiphysiodesis of an acetabulum fracture if the triradiate cartilage is open and the joint congruency if the triradiate cartilage is closed. Internal fixation can be used if surgery is being performed for associated non-orthopaedic injuries. Most vertically stable fractures are treated non-surgically. Fractures that are unstable vertically will require surgical treatment. Treatment of acetabulum fractures depends on the status of the triradiate cartilage. In older children, it is similar to the treatments used in adults. In children with open growth plates, the goal is to make sure the acetabulum continues growing. In all cases, the patients must be instructed to start physical therapy as soon as possible. Full recovery can be expected after stable pelvic fractures. Unstable pelvic fractures can lead to sequelae, the severity of which depend on the residual pelvic displacement and involvement of the growth plates that can cause epiphysiodesis. Surgery to correct these deformities is challenging. The most serious occur when the vertical displacement of the hemipelvis must be corrected. After an acetabulum fracture, removal of the growth blocker can be done in children under 10 years of age. In older children, acetabular dysplasia requires periacetabular osteotomy.

Medial patellofemoral ligament reconstruction in children: do osseous abnormalities matter?

PURPOSE: Management of post-traumatic patellar instability in children with osseous abnormalities is challenging because of the presence of an open physis. The aim of our study was to compare the rate of recurrence after isolated reconstruction of the medial patellofemoral ligament (MPFL) in children with or without osseous abnormalities. METHODS: The medical records of 25 children (27 knees) with recurrent patellar dislocation were reviewed. Each child underwent an isolated reconstruction of the MPFL using a hamstring graft. At the last follow-up, a clinical and radiographic evaluation was performed, including assessment of functional outcomes based on the Kujala score. Patients were compared in terms of the occurrence of a pre-existing osseous abnormality. RESULTS: The mean age at the time of the surgery was 13.8 years. Eleven patients had trochlear dysplasia (40%), three had a patella alta (11%) and seven had an increased TT-TG (26%). The recurrence rate was 3.7% (one patient), after a mean follow-up of 41.1 months. Recurrence was not more frequent in patients with preoperative anatomical predisposing factors. The mean Kujala score was 95. The mean time to return to practicing sports was 7.1 months. CONCLUSIONS: Isolated MPFL reconstruction is an effective option for the management of post-traumatic patellofemoral instability in skeletally immature patients. The results of this technique seem to be independent on either proximal or distal misalignments such as trochlear dysplasia, patella alta, or increased TT-TG.

Experience and volume are determinantive factors for operative management of supracondylar humeral fractures in children.

BACKGROUND: We compared radiographic and operative results of pediatric patients undergoing surgical treatment of displaced supracondylar humeral fracture (SCHF) according to the surgeon's experience. METHODS: During an 11-year period (2006-2016), we reviewed the medical records of 236 patients operated on for Gartland III SCHF in our institution. Operative (operative time, time to implants removal) and radiographic parameters (Baumann and lateral capitellohumeral angles) were assessed. A malalignment was defined if there was a difference in the Baumann angle or lateral capitellohumeral angles >15° or if malrotation existed compared with normative values. We compared surgeon experience and volume (number of patients operated on by year). RESULTS: In patients operated on by less experienced surgeons (<1 year, n = 69), operative time (61 vs. 41 minutes) and time to implant removal (48 vs. 40 days) were significantly longer (P < .001). Radiographic parameters did not differ between less and more experienced surgeons. Operative parameters improved through the 20 first cases of the younger surgeons. In surgeons managing fewer than 5 patients per year, malalignment and conversion to open reduction were more frequent (all P < .05). CONCLUSION: Experience and volume are 2 crucial parameters influencing the quality of management of pediatric patients undergoing surgical treatment for displaced SCHF. They should be taken into account in daily practice, especially when making the decision to operate on these patients out of day time.

An Efficient and Reproducible Protocol for Distraction Osteogenesis in a Rat Model Leading to a Functional Regenerated Femur.

This protocol describes the use of a newly developed external fixator for distraction osteogenesis in a rat femoral model. Distraction osteogenesis (DO) is a surgical technique leading to bone regeneration after an osteotomy. The osteotomized extremities are moved away from each other by gradual distraction to reach the desired elongation. This procedure is widely used in humans for lower and upper limb lengthening, treatment after a bone nonunion, or the regeneration of a bone defect following surgery for bone tumor excision, as well as in maxillofacial reconstruction. Only a few studies clearly demonstrate the efficiency of their protocol in obtaining a functional regenerated bone, i.e., bone that will support physiological weight-bearing without fracture after removal of the external fixator. Moreover, protocols for DO vary and reproducibility is limited by lack of information, making comparison between studies difficult. The aim of this study was to develop a reproducible protocol comprising an appropriate external fixator design for rat limb lengthening, with a detailed surgical technique that permits physiological weight-bearing by the animal after removal of the external fixator.

The lateral wedge augmentation trochleoplasty in a pediatric population: a 5-year follow-up study.

Patellofemoral instability in children requires surgery when recurrent dislocation occurs. The aim of this study is to report the 5-year clinical and radiographic outcomes following lateral wedge augmentation trochleoplasty of the femoral trochlea. This is a review of 23 (mean age: 12.5 years) patients who underwent surgery for recurrent patellar dislocations related to a flat trochlea. In every case, a lateral wedge augmentation trochleoplasty was performed with preservation of the growth plate. This surgery was consistently associated with a soft tissue procedure. All patients were reviewed for a clinical and radiographic evaluation [computed tomography (CT)-scan]. No case of recurrent patellar dislocation was reported and all patients were satisfied with the procedure; three patients reported anterior knee pain after physical activities. CT scan analysis revealed improvement of the trochlear shape measurements in all cases, but osteoarthritis lesions (narrowing of the lateral patellofemoral compartment) were visible on four CT scans. This trochleoplasty technique augmented by a soft tissue procedure on the extensor apparatus led to acceptable clinical mid-term results in terms of stability for patients with a flat trochlea (grade B according to Dejour classification). However, at the 5-year follow-up, four patients showed signs of osteoarthritis on CT scan evaluation. This warrants serious concern in this young population, and alternative methods should be considered whenever possible.

Bone lengthening: bridging joints, soft tissue releases, physiotherapy.

When we lengthen a bone in a child, the parents and the family circle are often obsessed by the amount a lengthening obtained. However, for the surgeon, lengthen a bone is quite pretty easy, but dealing with the joints above and below the lengthening area can be very challenging. Indeed, during the lengthening process, muscles and tendons will be progressively stretched, leading to potential joint contracture or even dislocation. The objective of the surgeon will be to avoid this situation. The first mean at disposal is the physiotherapy in order to help the joints to be more supple and to maintain their range of motion. The second mean is the soft tissue release before the surgery, during the lengthening process, or after the hardware removal when the capacities of physiotherapy are overdone. As a last resort, it can be helpful to bridge the joint to protect it during the lengthening.

Pseudoaneurysm of anterior tibial artery following a diaphyseal fracture of the tibia mimicking a malignant bone tumor.

Pseudoaneurysms of the lower limb are rare and frequently iatrogenics complications. Closed traumas are likely to generate lesions of the arterial wall, which generally become symptomatic at a later stage. The diagnosis of such vascular lesion is difficult because the symptomatology and the onset can be delayed. We herein report the case of a 15-year-old patient in whom the diagnosis of pseudoaneurysm of the anterior tibial artery was made 5 months after a non-displaced closed fracture of the tibial shaft. The radiographs were evocative of a malignant bone tumor. The study of vessels by a contrast-enhanced CT-scan enabled us to diagnose the pseudoaneurysm. Before the occurrence of late onset swelling, a history of trauma must be sought, even old.

Experience in Perioperative Management of Patients Undergoing Posterior Spine Fusion for Neuromuscular Scoliosis.

The objective of this investigation was to determine the outcome of spine fusion for neuromuscular (NM) scoliosis, using Unit Rod technique, with emphasis on complications related to preoperative general health. Between 1997 and 2007, 96 consecutive patients with neuromuscular scoliosis operated on with Unit Rod instrumentation were retrospectively reviewed. The inclusion criteria were diagnosis of NM scoliosis due to cerebral palsy (CP) and muscular dystrophy (DMD). Patient's preoperative general health, weight, and nutrition were collected. Different radiographic and clinical parameters were evaluated. There were 66 CP patients (59 nonwalking) and 30 DMD patients (24 nonwalking). Mean age at surgery was 16.5 years and 13.9 years, respectively. All radiographic measurements improved significantly. Wound infection rate was 16.7% (11% of reoperation rate in CP; 10% in DMD; 3 hardware removal cases). No pelvic fracture due to rod irritation was observed. Unit Rod technique provides good radiographic and clinical outcomes even if this surgery is associated with a high complication rate. It is a quick, simple, and reliable technique. Perioperative management strategy should decrease postoperative complications and increases outcome. A standardized preoperative patient evaluation and preparation including respiratory capacity and nutritional, digestive, and musculoskeletal status are mandatory prior to surgery.

Small bone islands: unusual clinical symptomatology.

Bone islands are usually considered benign, stable, nonprogressive lesions, radiographically characterized by an ovoid, round, or oblong homogeneously dense and sclerotic focus in the spongiosa, with a preference for the long bones and the pelvis. Benign solitary bone islands are usually believed to be asymptomatic, with no necessity for treatment. Symptomatic bone islands reported in the literature are characterized by a diameter greater than 2 cm, belonging to the category of giant bone islands. The authors report a rare case starting from a painful symptomatology and involving dense sclerotic bone lesions of less than 2 cm, thus falling into the category of small bone islands. The patient underwent a surgical resection to achieve complete recovery. Normally, small bone islands do not explain the pain in patients who present with symptomatology when they are detected during radiographic studies. Based on this case, the authors believe that even small bone islands can be the cause of symptomatology and justify a surgical procedure if all medical investigations suggest no other possible causes of the pain.

Siblings with vascular involvement associated with hereditary multiples exostosis.

Multiple hereditary exostoses are frequently observed in children, but vascular complications from exostoses in siblings are rare. We report the case of a 10-year-old boy, admitted for dyspnea and chest pain related to a hemothorax due to a right eighth rib exostosis. He was successfully treated by costal resection and chest tube drainage. In retracing his family history, another vascular involvement was discovered. His sister had presented a few years earlier with a spontaneous rupture of brachial artery with radial nerve palsy. To date, only a few cases of spontaneaous hemothorax related to a thoracic exostosis have been described, and to our knowledge, a family association of vascular lesions has not been reported yet. Patients with multiple hereditary exostoses require clinical and radiographic follow-ups during growing years. The main problem is determining the best way to identify dangerous exostoses that may cause vascular lesions. In association with standard surveillance of patients with multiple hereditary exostoses, we suggest performing specific examinations in cases of known thoracic lesions and for patients with a family history of vascular impingement.

Acute traumatic compartment syndrome of the leg in children: diagnosis and outcome.

BACKGROUND: Currently, the most common clinical scenario for compartment syndrome in children is acute traumatic compartment syndrome of the leg. We studied the cause, diagnosis, treatment, and outcome of acute traumatic compartment syndrome of the leg in children. METHODS: Forty-three cases of acute traumatic compartment syndrome of the leg in forty-two skeletally immature patients were collected from two large pediatric trauma centers over a seventeen-year period. All children with acute traumatic compartment syndrome underwent fasciotomy. The mechanism of injury, date and time of injury, time to diagnosis, compartment pressures, time to fasciotomy, and outcome at the time of the latest follow-up were recorded. RESULTS: Thirty-five (83%) of the forty-two patients were injured in a motor-vehicle accident and sustained tibial and fibular fractures. The average time from injury to fasciotomy was 20.5 hours (range, 3.9 to 118 hours). In general, the functional outcome was excellent at the time of the latest follow-up. No cases of infection were noted when fasciotomy was performed long after the injury. At the time of the latest follow-up, forty-one (95%) of forty-three cases were associated with no sequelae (such as pain, loss of function, or decreased sensation). The two patients who lost function had fasciotomy 82.5 and eighty-six hours after the injury. CONCLUSIONS: Despite a long period from injury to fasciotomy, most children who are managed for acute traumatic compartment syndrome of the leg have an excellent outcome. This delay may occur because acute traumatic compartment syndrome manifests itself more slowly in children or because the diagnosis is harder to establish in this age group. The results of the present study should raise awareness of late presentation and the importance of vigilance for developing compartment syndrome in the early days after injury. Fasciotomy during the acute swelling phase, even long after injury, produced excellent results with no cases of infection.

Progressive anterior vertebral bars: a study of 16 cases.

STUDY DESIGN: In a retrospective study, we report on 16 patients with congenital kyphosis due to progressively ossifying anterior unsegmented bars. OBJECTIVE: To specify the therapeutic strategy in such malformation. SUMMARY OF BACKGROUND DATA: Congenital kyphosis due to progressively ossifying anterior unsegmented bars is a particular and uncommon entity of congenital kyphosis. Progressive anterior vertebral bars result in slowly progressive kyphosis, which rarely lead to neurological compromise. Sagittal equilibrium of the spine is maintained by compensatory curves adjacent to the primary curve. METHODS: All patients had clinical assessment and successive measurements of segmental angle made on a standing lateral radiograph of the spine. Magnetic resonance imaging was obtained in four patients. Six patients were just observed. A brace was used in three. And seven were treated surgically. RESULTS: The compensatory capacity of the spine is reduced in lumbar area where there are few discs spaces below the bar. Presentation therefore tends to be at an earlier age and pain is more common.Magnetic resonance imaging enables definition of the structures immediately posterior to the bar and provides information regarding the integrity of the intervertebral disc. CONCLUSION: There is usually no need for surgery in thoracic and thoracolumbar localization. In lumbar localization, if the diagnosis is done early in childhood and if magnetic resonance imaging shows beyond the anterior ossification a normal T2-weighted magnetic resonance imaging disc space signal, desepiphysiodesis bar resection and cement interposition is mandatory. If the disc magnetic resonance imaging signal is abnormal or if the disc space is totally ossified, we propose a surgical correction of the kyphosis. For such cases a posterior wedge osteotomy seems to be the more suitable procedure.

Hexapodal external fixation in the management of children tibial fractures.

Some tibial fractures in children require surgical osteosynthesis, mostly achieved by an internal fixation. Indications for external fixation in the management of tibial fractures in children are limited to specific clinical situations when conventional treatments are contraindicated. The aim of this study is to report the results of tibial fractures management by hexapodal external fixation. Eleven children were included in this study and all of them were treated by a specific hexapodal external fixator, with a 12-month mean follow-up. In the whole series, initial deformities were perfectly corrected in nine cases, two patients showed residual deformity that did not require further surgery. The mean time for external fixation was 98 days. Hexapodal external fixation seems to be a simple and effective definitive method for the correction of three-dimensional traumatic deformities requiring surgical stabilization. Long-term follow-up will be necessary to evaluate residual deformities at the end of patient's growth.

Femoral lengthening over elastic stable intramedullary nailing in children using the monolateral external fixator.

The authors report preliminary results of femoral lengthening performed with monolateral external fixation over elastic stable intramedullary nailing in children. Seven femoral lengthenings were performed in six patients, at a mean age at surgery of 6.6 years (range 1.5-12 years). All lengthenings were performed due to limb length discrepancy (congenital hypoplasia in four patients, growth arrest secondary to neonatal infective osteoarthritis in one, type II sacral agenesis in one). In six cases the elastic nails realised a bipolar ascending construct, in one case a descending construct. Cases were reviewed at a mean time from removal of external fixator of 34.2 months (range 15-75 months). The mean lengthening obtained was 4.8 cm (range 3.8-6.0 cm). Mean consolidation index was 42.9 days/cm. No case of axial deviation requiring surgery and no case of deep infection were recorded. No case of fracture of the regenerate occurred after removal of the external fixator. There were two premature consolidations requiring mobilisation under general anaesthesia, and a case of failure of consolidation requiring surgery. The technique reported provides indisputable biomechanical advantages, particularly increasing stability at the site of osteotomy. The characteristics of implants make this method ideal for lengthenings in children.

Symptomatic os trigonum in children.

BACKGROUND: Symptomatic os trigonum is a rare condition well described in adults responsible for chronic ankle pain. To date there is no published case of successfully managed symptomatic os trigonum in children. METHODS: We retrospectively reviewed 4 paediatric patients (11-17) successfully operated on for a symptomatic os trigonum through a postero medial approach. One case was bilateral. RESULTS: Pain relief was postoperatively obtained in all cases. All of the patients were able to return to physical activities after 3 months. The mean follow up was 12 months. CONCLUSION: Symptomatic os trigonum may be responsible for chronic ankle pain in children and adolescents as well as in adults. The surgical treatment is effective in children.