Successful Elective Thoracoscopic Resection of Complicate Extralobar Bronchopulmonary Sequestration after Intrafoetal Vascular Laser Ablation: The Paediatric Surgeon's Point of View.

Few reports of laser coagulation for foetal bronchopulmonary sequestration (BPS), a rare congenital malformation characterised by the absence of tracheobronchial connection and the presence of a systemic feeding artery, have been published. Additionally, very few of them focus also on the postnatal management, with results limited and controversial. Postnatal treatment of residual malformation remains debated, hence the need to share our experience of a combined pre- and postnatal approach to complicated extra-lobar BPS. We report the case of a female foetus with the diagnosis of a pulmonary lesion. Due to mediastinal shift, unilateral compressive hydrothorax, ascites, and hydrops, a foetal treatment with ultrasound-guided laser coagulation of the anomalous vessel was performed. At birth, due to the persistence of the malformation, an elective delayed thoracoscopical surgery was performed. Prenatal laser ablation for complicated BPS is a life-saving procedure not always resulting in lesion disappearance. Thoracoscopical surgical exploration in case of persistent lesions at birth offers the possibility of a minimally invasive sequestrectomy feasible and safe.

Does harvesting of the semitendinosus tendon really spare the gracilis in pediatric anterior cruciate ligament reconstruction?

Purpose: The use of isolated semitendinosus tendon for Anterior Cruciate Ligament Reconstruction bears several advantages and is popular worldwide. It assumes that the gracilis tendon is spared. The aim of the study was to measure the surface area of the gracilis tendon in children who had undergone arthroscopic reconstruction of the anterior cruciate ligament using a semitendinosus tendon graft. Our hypothesis was that the gracilis tendon may be unintentionally and iatrogenically sectioned due to the anatomical proximity and the small size of the patients. Methods: Fifty patients who had undergone a magnetic resonance imaging preoperatively and postoperatively at 1 year from the surgery and who had been operated between January 2017 and March 2019 were included in this prospective series. The surface area of the gracilis tendon was measured on fat-saturated T2-weighted axial views at the widest point of the medial epicondyle of the femur. Age, sex, body weight, and height were documented. Results: One hundred magnetic resonance imaging of 50 knees were reviewed, from 34 boys (68%) and 16 girls (32%). The mean age was 14.5 years (10-18). The gracilis was visualized in all cases at 1 year postoperatively. The average tendinous surface area of the gracilis before the surgical procedure was 7.13 mm2 versus 8.73 mm2 at 1 year, representing an increase of 1.6 mm2 (p = 0.0003). Conclusions: This study demonstrated that harvesting of the semitendinosus for the purpose of Anterior Cruciate Ligament Reconstruction was a safe technique that preserves the gracilis. Level of evidence: III.

Prevalence and Detection of Meniscal Ramp Lesions in Pediatric Anterior Cruciate Ligament-Deficient Knees.

BACKGROUND: Anterior cruciate ligament (ACL) tears represent 13% of knee injuries in children. Medial meniscal tears are commonly associated with ACL ruptures. Ramp lesions correspond to posterior meniscocapsular tears of the medial meniscus. Depending on the study, the prevalence of ramp lesions is inconsistent. PURPOSE: To describe the prevalence of ramp lesions in children and adolescents and to investigate the sensitivity of magnetic resonance imaging (MRI) for diagnosing such lesions. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: We analyzed videos from arthroscopic ACL reconstruction (ACLR) in children. During these procedures, we systematically looked for potential ramp lesions. To do so, an arthroscope was passed through the intercondylar notch to visualize the posteromedial compartment. A needle was introduced at the site of a posteromedial portal to unfold the meniscocapsular junction to reveal any hidden meniscal tear. Surgical procedures were performed by 2 senior surgeons. Videos were blindly analyzed by a third surgeon. Preoperative MRIs were screened by 2 blinded, independent senior radiologists to look specifically for ramp lesions. RESULTS: Videos of 50 consecutive arthroscopic ACLRs concerning 32 boys and 18 girls were analyzed. Mean age at surgery was 14.2 years (range, 8.5-17.6 years). A total of 14 ramp lesions (28%) in 8 boys and 6 girls were identified. In addition, there were 22 tears of the meniscal body in 20 patients (40%). Arthroscopic and MRI findings did not correlate. Among 14 arthroscopically diagnosed ramp lesions, only 8 were detected on the MRI. Conversely, 12 patients had a ramp lesion detected on the MRI, which could not be confirmed intraoperatively. The sensitivity of MRI was 57% and the positive predictive value was 40%. CONCLUSION: A meniscal ramp lesion was present in 14 of 50 children (28%) undergoing ACLR. MRI has a low sensitivity for diagnosis of ramp lesions in children. Careful exploration of the posteromedial compartment is strongly recommended. Overlooking such lesions during ACLR may contribute to ongoing instability and higher re-rupture rates in these young patients.

Diffusion-weighted MRI for outcome prediction in early Legg-Calvé-Perthes disease: Medium-term radiographic correlations.

BACKGROUND: Outcome prediction at the early sclerotic stage of Legg-Calvé-Perthes disease (LCPD) is valuable to select patients likely to benefit from early surgery. The metaphyseal apparent diffusion coefficient (ADC) ratio correlated significantly with Herring's classification of LCPD in a preliminary study of 49 MRIs, in which values greater than 1.63 were associated with poor outcomes. The objective of this study was to determine whether the femoral neck ADC ratio, with the 1.63 cut-off, determined at the initial stage of LCPD correlated with medium-term radiographic outcomes. HYPOTHESIS: The metaphyseal ADC ratio correlates significantly with medium-term radiographic outcomes of LCPD. MATERIALS AND METHODS: A prospective study was performed in 27 children (mean age, 13 years; range, 9.5-16 years) who underwent 49 MRIs at the sclerosis or fragmentation stage of unilateral LCPD. ADCs measured bilaterally at the femoral head and neck were used to compute the corresponding ADC ratios between the affected and unaffected sides. The patients received regular follow-up for at least 5 years. The correlation between the ADC ratios and Stulberg grade at last follow-up was assessed. RESULTS: After a mean follow-up of 6.8 years (range, 5.2-8.4 years) from the date of the first MRI, 13 hips were Stulberg 1 or 2, 13 were Stulberg 3 or 4, and 1 was Stulberg 5. The metaphyseal ADC ratio increased significantly with the Stulberg grade (p<0.01). When only MRIs obtained at the early stage of sclerosis were considered, the correlation remained significant (p=0.03). It was also significant in the subgroup of surgically treated patients (p<0.0001) but was not significant in the subgroup without surgery (p=0.51). A metaphyseal ADC ratio greater than 1.63 was associated with a worse Stulberg grade (p=0.02). DISCUSSION/CONCLUSION: Diffusion-weighted MRI is a non-irradiating and non-invasive investigation that contributes to the management of LCPD when used in combination with morphological MRI sequences. Elevation of the femoral neck ADC is a finding of adverse prognostic significance that correlates with Herring's grade at the fragmentation stage and with Stulberg's grade at the healed stage. Early ADC elevation in the affected femoral neck can serve to select those patients most likely to benefit from early surgery before the fragmentation stage, i.e., before Herring's classification can be applied. LEVEL OF EVIDENCE: III, prospective uncontrolled study 3.

Planning for Bone Excision in Ewing Sarcoma: Post-Chemotherapy MRI More Accurate Than Pre-Chemotherapy MRI Assessment.

BACKGROUND: In determining the level of bone resection in Ewing sarcoma, the most suitable time at which to perform magnetic resonance imaging (MRI) remains controversial. Current guidelines recommend that surgical planning be based on MRI performed prior to neoadjuvant chemotherapy. The goal of this study was to determine whether pre-chemotherapy or post-chemotherapy MRI provides greater accuracy of tumor limits for planning bone excision in the management of Ewing sarcoma. METHODS: This was a single-center, retrospective study. MRI was performed using 3 sequences: T1-weighted, T1-weighted with contrast enhancement by gadolinium injection, and a fluid-sensitive sequence (STIR [short tau inversion recovery] or proton-density-weighted with fat saturation). The tumor extent as assessed on pre-chemotherapy and post-chemotherapy MRI was compared with histological measurement of the resected specimen. RESULTS: Twenty patients with Ewing sarcoma of a long bone were included. In 6 cases, the tumor was located on the femur, in 5, the tibia; in 5, the fibula; and in 4, the humerus. The median patient age at diagnosis was 9.7 years. We found greater accuracy of measurements from MRI scans acquired after chemotherapy than from those acquired before chemotherapy. For both pre-chemotherapy and post-chemotherapy MRI, the greatest accuracy was achieved with the nonenhanced T1 sequence. There was no benefit to gadolinium enhancement. The median difference between T1 MRI and histological measurements was 19.0 mm (interquartile range [IQR], 4.3 to 32.8 mm) before chemotherapy and 5.0 mm (IQR, 2.0 to 13.0 mm) after chemotherapy. Adding a minimum margin of 20 mm to the limit of the tumor on post-chemotherapy T1 MRI always led to safe histological margin. CONCLUSIONS: Post-chemotherapy MRI provided a more accurate assessment of the limits of Ewing sarcoma. Surgical planning can therefore be based on post-chemotherapy MRI. Surgical cuts can be, at minimum, 20 mm from the limits as seen on MRI.

Non-operative Management for Uncomplicated Appendicitis: An Option to Consider.

AIM: The main goal of our study was to assess a 7 days long course of antibiotics for acute uncomplicated appendicitis. MATERIALS AND METHODS: From March 2014 to November 2015, all patients diagnosed with acute appendicitis have been considered to be treated by only antibiotics. Inclusion criteria included clinical (tenderness), biological (C-reactive protein [CRP] < 50), and radiological features (diameter > 6 mm). All patients were treated with intravenous amoxicillin and clavulanic acid (100 mg/kg/day) for 2 days (six doses). At the end of the treatment, clinical and paraclinical examinations included blood samples at day 7 and ultrasound (US) scan at 3 months. RESULTS: A total of 166 patients were treated and followed up prospectively during the study period. Mean age at diagnosis was 10.8 ± 0.6 years. All children, but four were discharged with a clinical improvement after 48 hours and six intravenous antibiotics injection according to our protocol. Four children required surgery during the initial hospitalization period.Initial ultrasound scan showed a mean diameter of 7.85 ± 1.6 mm, with inflamed fat in 124 patients (74.7%). At Day 7, the diameter was 5.2 ± 1.6 mm (p < 0.0001).During a median follow-up of 18.8 months (3.5-18), 22 patients (13.25%) had to be managed for a novel episode of acute appendicitis after a median period of 138 days (13-270). None had to be managed for a complicated appendicitis. CONCLUSION: Non-operative treatment (NOT) is a safe alternative for the management of uncomplicated acute appendicitis in children. Further study should be conducted to determine relapse risk factors.

Relationship between tibial spine size and the occurrence of osteochondritis dissecans: an argument in favour of the impingement theory.

PURPOSE: Pathophysiology of osteochondritis dissecans (OCD) of the medial femoral condyle remains uncertain. Specifically, the relationship between the size of the anterior tibial spine (ATS) and the presence of OCD has not been explored. The purpose of this study was to evaluate the relationship between ATS size and the occurrence of OCD. METHODS: Seventy-nine children between 8 and 17 years of age were included in two groups: OCD (n = 37) and control (n = 42). The groups were matched in terms of age, gender, BMI and weight. Two independent observers performed an MRI analysis of the size of the tibial spine and intercondylar notch relative to the size of the respective epiphyses. For this study, the "S ratio" was calculated by dividing the height of the tibial spine by the height of the tibial epiphysis. The "N ratio" was calculated by dividing the height of the notch by the height of the femoral epiphysis. These two ratios for both groups were compared using Student's t test. RESULTS: The mean value of the S ratio in the OCD group was 0.39 ± 0.06; the mean value of the S ratio in the control group was 0.32 ± 0.03 (P = 0.004). The mean value of the N ratio in the OCD group was 0.70 ± 0.08; the mean value of the N ratio in the control group was 0.70 ± 0.07 (n.s.). CONCLUSION: This study's findings confirm our hypothesis that patients with OCD have a more prominent tibial spine than in patients without OCD. LEVEL OF EVIDENCE: IV.

Non-contrast-enhanced MR angiography using time-spin labelling inversion pulse technique for detecting crossing renal vessels in children with symptomatic ureteropelvic junction obstruction: comparison with surgical findings.

OBJECTIVES: Investigate the feasibility and evaluate the accuracy of non-contrast-enhanced MR angiography (NC-MRA) using time-spin labelling inversion pulse (time-SLIP)to identify crossing renal vessels (CRVs) in children requiring surgical treatment of ureteropelvic junction (UPJ) obstructionand compare to laparoscopic findings. MATERIALS AND METHODS: Nineteen children ranging from 6 to 16 years of age underwent NC-MRA using the time-SLIP technique before surgery. Two independent readers analysed the MRA images. Number of renal arteries and presence or absence of CRVs were identified and compared with surgicalfindings. Image quality was assessed, as well as the presence of CRVs and measurement of renal pelvis diameter. Intra and inter-reader agreement was calculated using Cohen's kappa coefficient and Bland-Altman plots. RESULTS: The overall image quality was fair or good in 88% of cases. NC-MRA demonstrated CRVs at the level of the obstruction in 10 children and no CRV in 9 children. All were confirmed intra-operatively except in one of the nine children. Sensitivity, specificity, NPV, PPV for predicting CRVs were 92%, 100%, 100% and 87.5%, respectively, for both readers. CONCLUSION: NC-MRA is a good alternative to contrast-enhanced MRA and CT scanning for identifying CRVs in children with symptomatic UPJ. KEY POINTS: • Time-SLIP technique offers acceptable imaging quality for identifying crossing renal vessel. • Time-SLIP technique is easy to apply to the renal MRA examination. • Time-SLIP technique is an alternative to contrast-enhanced MRA and CT scanning.

Complex communicating bronchopulmonary foregut malformation with pancreatic heterotopy depicted with fetal magnetic resonance imaging: a case report.

Bronchopulmonary foregut malformation (BPFM) is a group of rare congenital anomalies that affect the respiratory and upper gastrointestinal tracts. We report here the first case of prenatal depiction of communicating BPFM, including extrapulmonary sequestration and foregut cyst, both with pancreatic differentiation. Magnetic resonance imaging on the fetus confirmed a polymalformative syndrome with right-lung and gastric cysts and allowed the detection of respiratory and alimentary tracts communication and aberrant feeding vessels. Diagnosis was confirmed after birth by multidetector computed tomography and postnatal pathologic findings. The patient, a boy, underwent surgery for respiratory distress at 4 weeks of life. This singular case confirms the benefits of early surgery for communicating BPFM.

A rare cause of anaemia associated with hypertension in a 14-year-old girl.

We report a rare example of anaemia and hypertension due to an incomplete Carney triad in a 14-year-old girl with no previous medical history. This rare non-familial syndrome generally involves two disparate tumours: gastrointestinal stromal tumour, paraganglioma and/or pulmonary chondroma. The complete triad is a syndrome that involves at least five loci: stomach, oeophagus, lung, the paraganglionic system, adrenal (cortex or medulla). The pathogenesis is unclear as these tumours have different embryological origins. Surgical treatment is necessary, and long-term follow-up is advisable as patients with Carney triad may re-present with tumour(s), even several years after the first presentation.

Coregistration of prechemotherapy PET-CT for planning pediatric Hodgkin's disease radiotherapy significantly diminishes interobserver variability of clinical target volume definition.

PURPOSE: To assess the interobserver variability in clinical target volume (CTV) definitions when using registered (18)F-labeled deoxyglucose positron emission tomography (FDG-PET-CT) versus side-by-side image sets in pediatric Hodgkin's disease (HD). METHODS AND MATERIALS: Prechemotherapy FDG-PET-CT scans performed in the treatment position were acquired from 20 children (median age, 14 years old) with HD (stages 2A to 4B) and registered with postchemotherapy planning CT scans. The patients had a median age of 14 years and stages of disease ranging between 2A and 4B. Image sets were coregistered using a semiautomatic coregistration system. The biological target volume was defined on all the coregistered images as a guide to defining the initial site of involvement and to avoid false-positive or negative results. Five radiation oncologists independently defined the CTV for all 20 patients: once using separate FDG-PET-CT images as a guide (not registered) to define CTVa and once using the registered FDG-PET-CT data to define CTVb. The total volumes were compared, as well as their coefficients of variation (COV). To assess the interobserver variability, the percentages of intersection between contours drawn by all observers for each patient were calculated for CTVa and for CTVb. RESULTS: The registration of a prechemotherapy FDG-PET-CT scan caused a change in the CTV for all patients. Comparing CTVa with CTVb showed that the mean CTVb increased in 14 patients (range, 0.61%-101.96%) and decreased in 6 patients (range, 2.97%-37.26%). The COV for CTVb significantly decreased for each patient; the mean COVs for CTVa and CTVb were 45% (21%-65%) and 32% (13%-57%), respectively (p = 0.0004). The percentage of intersection among all CTVbs for the five observers increased significantly by 89.77% (1.99%-256.41%) compared to that of CTVa (p = 0.0001). CONCLUSIONS: High observer variability can occur during CT-based definition of CTVs for children diagnosed with HD. Registration of FDG-PET and planning CT images resulted in significantly greater consistency of tumor volume definition.

Efficacy of propranolol in hepatic infantile hemangiomas with diffuse neonatal hemangiomatosis.

We report the rapid and dramatic efficacy of propranolol in 8 infants with infantile hepatic hemangiomas. The degree of response varied from a significant improvement to a complete resolution of hepatic lesions. Heart failure and hypothyroidism resolved, and hepatomegaly decreased. No side-effects of the drug were noted.

[Shoulder pain: imaging examinations]. / Epaule douloureuse: quels examens d'imagerie demander?

Non-traumatic shoulder pain is a diagnostic challenge for clinicians. Usually, the clinical examination is supplemented by nowadays well-defined imaging studies. Radiography is the first examination to be requested on a systematic basis. It always includes several views to study the whole scapular region (glenohumeral joint, subacromial space, acromioclavicular joint etc.). If the radiographic examination is not precise enough, a noninvasive and non-irradiating examination is performed, either ultrasonography or magnetic resonance imaging. The latter seems to be more comprehensive than ultrasonography. However, the usefulness of the association radiography-ultrasonography should be emphasized: both examinations are perfectly complementary, inexpensive and easy to access. Invasive examinations, such as CT arthrography, are still too often requested following a radiological examination. Since they do not investigate the whole shoulder, they should be limited to the investigation of specific diseases, often as part of presurgical assessments required for or by the orthopedic surgeon.