Changes in gait patterns after anterior cruciate ligament reconstruction in children.

PURPOSE: Anterior cruciate ligament reconstruction (ACLR) in children is indicated to reduce recurrent knee instability and further damage to the joint. Postoperative modified gait pattern was reported in the adult population after ACLR. The aim of this study was to analyse gait abnormalities, and especially knee and ankle adaptations during gait in children after ACLR. METHODS: A prospective study was performed between 2018 and 2022 on 50 children, aged nine to 15 years with unilateral ACL deficiency. Changes in gait pattern were evaluated by gait analysis before surgery and at the latest follow-up of 24 months. Kinematic data of ACL-deficient limb were compared to contralateral limb and to those of a matched control group of healthy children. RESULTS: Compared to control group, knee flexion was decreased for both ACL-deficient and contralateral knee before surgery. Decreased knee flexion during gait cycle persisted at latest follow-up. Ankle kinematics showed decreased dorsal flexion for both ACL-deficient and contralateral limb before surgery. At latest follow-up, ankle kinematics were modified for ACL-reconstructed limbs only at initial contact and showed no significant difference for contralateral limb compared to the control group. CONCLUSION: In children with ACL injury, abnormal gait patterns persist two years after ligament reconstruction, in spite of extensive rehabilitation and no clinical complaints. These findings might guide neuromuscular training to improve clinical outcomes and reduce the rerupture rate.

Influence of a posteromedial meniscocapsular injury on the knee anterior laxity. A cadaveric study.

PURPOSE: The number of anterior cruciate ligament (ACL) injuries has considerably increased in the recent years, especially in young adults and adolescents. Associated meniscal tears increase anterior and rotary laxity. Posterior peripheral meniscocapsular tear of medial meniscus is also called ramp lesion. Prevalence of 9% to 17% in adults and up to 23% in pediatric population has been reported. The aim of this study was to determine anterior laxity of cadaveric ACL-deficient knees with several size of ramp lesions. METHODS: Fresh cadaveric knees were explored. Major osteoarthritis and/or ACL and meniscal tears on arthroscopy were exclusion criteria. Mean age at death was 86 years old. Dynamic laximetry with GNRB® device was made in several conditions: Knee prior to any procedure, after arthroscopic exploration, after ACL section, and then after increasing sizes of ramp lesions up to 30 mm. Anteroposterior laxity was measured with 2 loading forces successively (134N and 200N). RESULTS: After ACL section only, tibiofemoral joint anterior laxity was significantly increased. Mean increase was 156% regardless of the loading force. No statistical laxity difference was found between knees with ACL section only and knees with ACL and meniscal section for any size of ramp lesions. Increasing size of ramp lesion was not correlated with increasing of laxity. CONCLUSION: We could not find a threshold size of ramp lesion which increases knee anterior laxity. We were not able to determine a threshold recommending a ramp lesion repair.

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.

Treatment of hallux valgus in children and adolescents.

Juvenile hallux valgus is one of the most common pathologies of the forefoot in children and adolescents. Nevertheless, its treatment is still controversial. This deformity has some distinct anatomical features, particularly a lateral tilt of the articular facet of the head of the first metatarsal and congenital metatarsus adductus, which often occur in combination. Some mediocre surgical treatment results can be explained by the lack of correction of all these factors when we approach the problem as we would in adults. A double osteotomy to correct the DMAA and varus of the first metatarsal is a good solution in most cases with satisfactory functional outcomes. A percutaneous approach seems efficient in the pediatric population, given that the periosteum and growth plates, which are very active in younger children, help the osteotomies to heal and remodel. Guided growth surgery - using this approach is a viable alternative in this age bracket. Finally, minimally invasive surgery for juvenile hallux valgus allows another surgery to be done on minimally or undamaged tissues if needed later on.

Clinical predictive model of lumbar curve Cobb angle below selective fusion for thoracic adolescent idiopathic scoliosis: a longitudinal multicenter descriptive study.

PURPOSE: To implement a clinically applicable, predictive model for the lumbar Cobb angle below a selective thoracic fusion in adolescent idiopathic scoliosis. METHODS: A series of 146 adolescents with Lenke 1 or 2 idiopathic scoliosis, surgically treated with posterior selective fusion, and minimum follow-up of 5 years (average 7) was analyzed. The cohort was divided in 2 groups: if lumbar Cobb angle at last follow-up was, respectively, ≥ or < 10°. A logistic regression-based prediction model (PredictMed) was implemented to identify variables associated with the group ≥ 10°. The guidelines of the TRIPOD statement were followed. RESULTS: Mean Cobb angle of thoracic main curve was 56° preoperatively and 25° at last follow-up. Mean lumbar Cobb angle was 33° (20; 59) preoperatively and 11° (0; 35) at last follow-up. 53 patients were in group ≥ 10°. The 2 groups had similar demographics, flexibility of both main and lumbar curves, and magnitude of the preoperative main curve, p > 0.1. From univariate analysis, mean magnitude of preoperative lumbar curves (35° vs. 30°), mean correction of main curve (65% vs. 58%), mean ratio of main curve/distal curve (1.9 vs. 1.6) and distribution of lumbar modifiers were statistically different between groups (p < 0.05). PredictMed identified the following variables significantly associated with the group ≥ 10°: main curve % correction at last follow-up (p = 0.01) and distal curve angle (p = 0.04) with a prediction accuracy of 71%. CONCLUSION: The main modifiable factor influencing uninstrumented lumbar curve was the correction of main curve. The clinical model PredictMed showed an accuracy of 71% in prediction of lumbar Cobb angle ≥ 10° at last follow-up. LEVEL OF EVIDENCE IV: Longitudinal comparative study.

Bone Lengthening with a Motorized Intramedullary Nail in 34 Patients with Posttraumatic Limb Length Discrepancies.

The Fitbone® motorized nail system has been used to correct limb length discrepancies (LLD) for several years. This study focuses on its application in posttraumatic limb lengthening surgery, its outcome and challenges. MATERIALS AND METHODS: A prospective, single center study was conducted between 2010 and 2019 in patients treated with motorized lengthening nails. The inclusion criteria were symptomatic LLD of 20 mm or more. An imaging analysis was done using TraumaCad® software (Brainlab AG, Munich, Germany) to compare frontal alignment angles and limb length discrepancy (LLD) on preoperative and latest follow-up radiographs of the lower limbs. RESULTS: Thirty-four patients were included with a mean age of 28.8 ± 9.7 years, a mean follow-up of 27.8 ± 13 months and a mean hospital stay of 4.4 ± 1.7 days. The mean LLD was 44 ± 18 mm in 29 femoral and 32 ± 8 mm in 4 tibial cases, which was reduced to less than 10 mm in 25/34 (74%) patients. The mean healing index was 84.6 ± 62.5 days/cm for femurs and 92 ± 38.6 days/cm for tibias. The mean time to resume full weight-bearing without walking aids was 226 days ± 133. There was no significant difference between preoperative and final follow-up alignment angles and range of motion. The mechanical lateral distal femoral angle (mLDFA) was corrected in the subgroup of 10 LLD patients with varus deformity of the femur (preoperative 95.7° (±5.0) vs. postoperative 91.5° (±3.4), p = 0.008). According to Paley's classification, there were 14 problems, 10 obstacles and 2 complications. DISCUSSION: Six instances of locking screw pull out, often requiring reoperation, raise the question of whether a more systematic use of blocking screws that provide greater stability might be indicated. Lack of compliance can lead to poor outcomes, patient selection in posttraumatic LLD patients is therefore important. CONCLUSION: Limb lengthening with a motorized lengthening nail for posttraumatic LLD is a relatively safe and reliable procedure. Full patient compliance is crucial. In-depth knowledge of lengthening and deformity correction techniques is essential to prevent and manage complications.

Influence of the sublaminar band density in the treatment of Lenke 1 adolescent idiopathic scoliosis.

INTRODUCTION: Optimal pedicle screw density for the treatment of adolescent idiopathic scoliosis (AIS) remains unknown. It is not clear whether higher implant density results in better clinical outcomes. Large variability in implant density exists among hybrid or all screw constructs. Significant heterogeneity exists with respect to the number of sublaminar bands (SB) used, and the influence of SB density on curve correction in the treatment of AIS. HYPOTHESIS: We hypothesize that increased SB density does not improve sagittal or coronal plane curve correction. METHODS: A single-center, retrospective study of 131 consecutive patients (118 females) with Lenke 1 adolescent idiopathic scoliosis, all operated between 2012 and 2015 by two surgeons using identical surgical technique and type of instrumentation (SB hybrid instrumentation treatment). SB density was measured using the number of SB reported as well as the number of vertebrae instrumented. Radiographic measurements included preoperative thoracic curve flexibility, Cincinnati reduction index (CRI), and postoperative thoracic Cobb (POCC) and kyphosis (POKC) angle correction measured on immediate postoperative radiographs and at 2 years postoperatively. RESULTS: Median patient age was 15.6 years (IQR, 12-18). The median SB density was 0.4 (IQR 0.4-0.5). No statistically significant correlation was identified between SB density and CRI (p=0.71), POCC (p=0.55), or POKC (p=0.61) at 2-years postoperatively. Preoperative curve flexibility was found to have significant effect both on immediate (r=-3.02, p<0.001) and 2-year (r=-2.69, p<0.001). DISCUSSION: SB utilized as a part of a hybrid construct for patients with flexible Lenke I AIS achieve satisfactory deformity correction regardless of SBd. The use of low SB density is appropriate for a subset of patients with flexible Lenke 1 adolescent idiopathic scoliosis.

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.

Correction of hypokyphosis in thoracic adolescent idiopathic scoliosis using sublaminar bands: a 3D multicenter study.

INTRODUCTION: The comparison of implants and correction methods remain controversial in AIS. Excellent frontal and axial correction rates have been reported with all-screw constructs, but at the expense of sagittal alignment, which has a tendency to flatten postoperatively. Posteromedial translation using hybrid constructs seems to preserve and improve thoracic kyphosis (TK), but no series exist to date with a significant number of hypokyphotic patients. In addition, the measures of TK in 2D are often wrong in severe AIS due to axial rotation. The goals of this study were therefore to analyze the 3D radiological outcomes of a group of hypokyphotic AIS patients operated with sublaminar bands. METHODS: 35 consecutive AIS hypokyphotic patients (T4T12 <15°) operated in three centers were included, with a minimum 2-year follow-up. The surgical technique was similar in all centers, associating lumbar pedicle screws and thoracic sublaminar bands. Posteromedial translation was the main correction technique, and no patient underwent prior anterior release. 3D spinal reconstructions were performed preoperatively, postoperatively and at the latest follow-up by an independent observer using SterEOS (EOS imaging, Paris, France), and 2D and 3D measurements were compared. In addition, a new 3D parameter [sagittal shift of the apical vertebra (SSAV)], reflecting the translation of the apical vertebra of the main curve in the patient sagittal plane, was described and reported. RESULTS: The age of the cohort was 16 years and the number of sublaminar bands used for correction averaged 6 (±1.5). T1T12 and T4T12 sagittal Cobb angles appeared to be overestimated on 2D postoperatively (3°, p = 0.002 and 4°, p < 0.001, respectively). Hence, only 3D measurements were kept for the quantitative analysis of the postoperative correction. T4T12 TK significantly increased after surgery (average 8° ± 7°, p < 0.001), but 11 patients (31.4%) remained hypokyphotic. Seven out of the eight patients (87.5%) who presented a thoracic lordosis (i.e., T4T12 <0°) preoperatively were corrected after surgery (mean gain 16° ± 4°). A posterior shift (positive SSAV) of the apical vertebra was reported in 24 patients (68.6%). In this subgroup, the mean SSAV was +2 cm (±1). Good correlation was found between the SSAV and the postoperative change in 3D T4T12 kyphosis (r = 0.62). CONCLUSION: Measures in 2D tend to overestimate sagittal alignment and are not sufficient to evaluate postoperative correction. SSAV is a new 3D parameter reflecting the TK change that needs to be further investigated and used in the future. This series confirms that sublaminar bands should be considered in hypokyphotic patients, since thoracic sagittal alignment was restored in 68.6% of the cases.

Magnetically controlled growing rod in early onset scoliosis: a 30-case multicenter study.

PURPOSE: Preliminary results of magnetically controlled growing rods (MCGR) are encouraging. However, only short case series of MCGR for the treatment of early onset scoliosis (EOS) have been reported. Our aim was to evaluate its effectiveness and complications. METHODS: We report a 30-case retrospective, consecutive, multicenter series of MCGR. Effectiveness was judged upon: deformity correction and difficulties to achieve desired distraction. Secondary endpoints included complications and revision surgeries. RESULTS: Median age at surgery was 9.1 years (5-13). Mean follow-up was 18.4 months (12-33.9). Mean Cobb angle was 66° preoperatively and 44° at latest follow-up. MCGR has avoided an average of 2.03 scheduled surgical procedures per patient compared to traditional growing rod (GR). The intended total length gain was 40.1 mm per patient (5-140) and the total measured length gain was 21.9 mm (45.5% discrepancy). There were 24 complications: 7 proximal pull-outs of the hooks, 3 rod breakages, 6 failures of the lengthening of which 4 complete blockages and 2 complete blockages followed by backtracking, 1 proximal junctional kyphosis, 1 wound dehiscence, 1 superficial infection, 1 deep infection requiring implant removal, 1 pulmonary embolism, 1 pulmonary insufficiency, 1 secondary lumbar scoliosis, and 1 painful outpatient distraction. Eight patients had a gradual loss of effectiveness of distractions. There were 13 revision surgeries in 9 patients. CONCLUSIONS: MCGR provides satisfactory deformity correction and avoids repeated surgical procedures for lengthening. However, it has substantial complication rate. Although less frequent than in GR, the law of diminishing returns also applies to MCGR.

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.

Triple osteotomy of the pelvis for Legg-Calve-Perthes disease: a mean fifteen year follow-up.

PURPOSE: This study presents the results of a prospective consecutive cohort of patients with Legg-Calvé-Perthes disease (LCPD) operated with triple osteotomy of the pelvis (TOP) between 1989 and 2005. We attempted to determine whether the results of TOP remain stable with time and consequently lower the risk of subsequent osteoarthritis. The primary study aims were to determine the maintenance of head coverage and joint congruity, and functional outcomes of this surgery. METHODS: Forty-five patients with a mean follow-up of 15.2 years (range eight to 24) were included. RESULTS: At latest follow-up, two patients were lost to follow-up, and two required a surgical reoperation. Cumulative maintenance of head coverage and joint congruity rate for all TOP was 84.6 % (95 % CI: 82.3-90.6 %) at 15 years. Factors significantly associated with poor long-term results were the age at diagnosis and Greene index. CONCLUSION: TOP in LCPD provides satisfactory and reproducible long-term clinical results.

Ultrasound-guided Percutaneous Medial Pinning of Pediatric Supracondylar Humeral Fractures to avoid Ulnar Nerve Injury.

BACKGROUND: Medial pinning is one of the most controversial aspects of the surgical treatment of supracondylar fractures (SHF) owing to the risk of ulnar nerve injury. AIM: To evaluate the safety and usefulness of medial pinning for SHF using ultrasound imaging for ulnar nerve visualization. METHODS: Fifteen children, with a mean age of 60 months, with displaced SHF were treated with a crossed-pinning configuration after fracture reduction. Intraoperative ultrasound was used to guide medial pin insertion to avoid ulnar nerve injury. RESULTS: Cubital tunnel anatomy was easily identified in all children. All children showed a subluxating ulnar nerve that required elbow extension to about 90º before medial pin insertion. None suffered ulnar nerve dysfunction after using the referred technique. CONCLUSIONS: Although technically demanding, ultrasound may be a valuable adjuvant to avoid ulnar nerve injury while performing a medial pinning in pediatric SHF.

Percutaneous correction of persistent severe metatarsus adductus in children.

BACKGROUND: Percutaneous techniques for the correction of foot deformities are gaining popularity in the adult population, but remain poorly explored in children. Of the several surgical techniques described to treat persistent severe metatarsus adductus (MA) deformity in children, neither was percutaneous. The purpose of the study was to describe a percutaneous technique for MA correction in children, to report the outcomes, and to discuss the advantages it offers. METHODS: We designed a prospective study on 34 consecutive feet with MA deformity from 26 children undergoing percutaneous correction. All operated feet had severe, rigid MA deformities, most of which were components of residual/recurrent clubfoot deformities. The mean age at surgery was 5.7 years and the mean follow-up was 55.2 months. For clinical evaluation, we used the bisector method; the first cuneometatarsal angle and metatarsal-metaphyseal angle measured in weight-bearing radiographs and AOFASf score were determined preoperatively and postoperatively. In unilateral cases, we used the contralateral foot measurements as control. The operating time and the hospitalization time were also recorded. The surgical technique consisted of performing the Cahuzac procedure for MA correction with a percutaneous approach. RESULTS: At the final follow-up all feet presented a normal heel bisector line. Radiologic parameters were normalized when compared with control feet. The mean surgical and hospitalization time was 14 minutes and 6 hours, respectively. Mean AOFAS score improved from 78 to 98. CONCLUSIONS: A minimally invasive percutaneous technique allowed a successful correction of MA deformity in children and resulted in a substantive decrease in both surgical and hospitalization time and better cosmetic results. LEVEL OF EVIDENCE: Level II.

Complications in pediatric spine surgery using the vertical expandable prosthetic titanium rib: the French experience.

STUDY DESIGN: Multicenter retrospective study of 54 children. OBJECTIVE: To describe the complication rate of the French vertical expandable prosthetic titanium rib (VEPTR) series involving patients treated between August 2005 and January 2012. SUMMARY OF BACKGROUND DATA: Congenital chest wall and spine deformities in children are complex entities. Most of the affected patients have severe scoliosis often associated with a thoracic deformity. Orthopedic treatment is generally ineffective, and surgical treatment is very challenging. These patients are good candidates for VEPTR expansion thoracoplasty. The aim of this study was to evaluate the potential complications of VEPTR surgery. METHODS: Of the 58 case files, 54 were available for analysis. The series involved 33 girls and 21 boys with a mean age of 7 years (range, 20 mo-14 yr and 2 mo) at primary VEPTR surgery. During the follow-up period, several complications occurred. RESULTS: Mean follow-up was 22.5 months (range, 6-64 mo). In total, 184 procedures were performed, including 56 VEPTR implantations, 98 expansions, and 30 nonscheduled procedures for different types of complications: mechanical complications (i.e., fracture, device migration), device-related and infectious complications, neurological disorders, spine statics disturbances. Altogether, there were 74 complications in 54 patients: a complication rate of 137% per patient and 40% per surgery. Comparison of the complications in this series with those reported in the literature led the authors to suggest solutions that should help decrease their incidence. CONCLUSION: The complication rate is consistent with that reported in the literature. Correct determination of the levels to be instrumented, preoperative improvement of nutritional status, and better evaluation of the preoperative and postoperative respiratory function are important factors in minimizing the potential complications of a technique that is used in weak patients with complex deformities.

The ß5/focal adhesion kinase/glycogen synthase kinase 3ß integrin pathway in high-grade osteosarcoma: a protein expression profile predictive of response to neoadjuvant chemotherapy.

To date, chemosensitivity to neoadjuvant chemotherapy of patients with high-grade osteosarcoma is evaluated on surgical resection by evaluation of the percentage of necrotic cells. As yet, no predictive profile of response to chemotherapy has been used in clinical practice. Because we have previously shown that the integrin pathway controls genotoxic-induced cell death and hypoxia, we hypothesized that in primary biopsies, expression of proteins involved in this pathway could be associated with sensitivity to neoadjuvant chemotherapy in high-grade osteosarcoma. We studied ß1, ß3, and ß5 integrin expression and integrin-linked kinase, focal adhesion kinase (FAK), glycogen synthase kinase 3ß (GSK3ß), Rho B, angiopoietin-2, ß-catenin, and ezrin expression by immunohistochemistry in 36 biopsies of osteosarcomas obtained before treatment. All patients received a chemotherapy regimen in the neoadjuvant setting. An immunoreactive score was assessed, combining the percentage of positive tumor cells and staining intensity. We evaluated the correlation of the biomarkers with response to chemotherapy, metastasis-free survival, and overall survival. A combination of 3 biomarkers (ß5 integrin, FAK, and GSK3ß) discriminated good and poor responders to chemotherapy, with the highest area under the curve (89.9%; 95% confidence interval, 77.4-1.00) and a diagnostic accuracy of 90.3%. Moreover, high expression of ezrin was associated with an increased risk of metastasis (hazard ratio, 3.93; 95% confidence interval, 1.19-12.9; P = .024). We report a protein expression profile in high-grade osteosarcoma associating ß5 integrin, FAK, and GSK3ß that significantly correlates with poor response to neoadjuvant chemotherapy. This biomarker profile could help select patients for whom an alternative protocol using inhibitors of this pathway can be proposed.

A subscapularis-preserving arthroscopic release of capsule in the treatment of internal rotation contracture of shoulder in Erb's palsy (SPARC procedure).

The purpose of this study was to evaluate a minimally invasive subscapularis-preserving arthroscopic release of capsule in the treatment of internal rotation contracture of the shoulder due to Erb's palsy. We performed our procedure (subscapularis-preserving arthroscopic release of capsule) in 10 paediatric shoulders with an average age of 20.2 months and followed them for an average period of 41.5 months. All the patients were assessed clinically and radiologically preoperatively and postoperatively at regular intervals. The Mallet scoring system was used for analysing the results. The average gain in passive external rotation was 50°. The active internal rotation was preserved in all the cases. With the mid-term follow-up, there was no loss of the gained external rotation or the recurrence of internal rotation contracture of the shoulder. Our hypothesis has achieved its goal in preserving subscapularis, active internal rotation and treatment of internal rotation contracture of the shoulder. The success of this procedure lies in the early identification of starting of internal rotation contracture and early surgical intervention to prevent progressive permanent glenohumeral osseocartilaginous deformity.

Arthroscopic release for shoulder internal rotation contracture secondary to brachial plexus birth palsy: clinical and magnetic resonance imaging results on glenohumeral dysplasia.

Internal rotation contracture of the shoulder in brachial plexus birth palsy frequently leads to shoulder dysplasia. Six children underwent anterior arthroscopic release sparing the subscapularis. Clinical examination and MRI were performed preoperatively and repeated at the 5-year follow-up. MRI was carried out for assessment of glenohumeral dysplasia. Passive external rotation was improved by 63.3° without any limitation of active internal rotation. Active antepulsion/abduction was improved by 90°. Remodeling of the glenoid and improved coverage of the humeral head were observed in all cases. Shoulder arthroscopic release sparing the subscapularis seems to be an efficient procedure to restore external rotation without affecting active internal rotation.

Reconstruction and anticipatory Langenskiöld procedure in traumatic defect of tibial medial malleolus with type 6 physeal fracture.

Traumatic osteoarticular or ligament defect of the tibial medial malleolus is a rare entity in children. Associated lesions may include soft tissue and joint defect, subsequent instability of the ankle, and growth arrest. We report here, the case of an 11-year-old boy, a victim of a severe trauma to the ankle, managed by an original technique. It combined a reconstruction by a composite iliac crest and gluteal fascia graft, an anticipatory Langenskiold procedure, and a serratus anterior muscle flap. This original technique proved to be a suitable alternative in this type of trauma.

Remodelling of vertebral endplate subchondral bone in scoliosis: a micro-CT analysis in a porcine model.

BACKGROUND: Disc degeneration has been correlated with alteration of bone density of adjacent vertebral bodies. Abnormal mechanical loading appears in scoliosis as compared to normal spines. How vertebral endplate was remodelled in scoliosis is not well understood. METHODS: We conducted a micro-CT analysis of subchondral bone of the vertebral endplate at the curve apex in a porcine scoliosis model. Two adjacent thoracic T(5)-T(6) and lumbar L(1)-L(2) levels were instrumented in six four-week-old pigs with a custom offset implant connected by a flexible stainless steel wire. Two months after implantation, three cylindrical specimens were harvested into the vertebral endplate of each of the scoliosis levels: centre, convexity and concavity, and from the dorsal T(9)-T(10) vertebral units obtained from nine three-month-old non-instrumented pigs used as controls. Micro-CT analysis was carried out on each specimen. FINDINGS: In the concavity of the scoliotic spine, bone volume fraction, trabecular thickness, and trabecular separation significantly increased whereas in the convexity, only trabecular separation increased. Connectivity index and trabecular number decreased significantly. INTERPRETATION: This was the first micro-CT study of subchondral bone microarchitecture of the scoliotic vertebral end plate. At the curve apex, increased compression in the concavity induced an osteogenic process. In the convexity, diminished compression caused an osteolytic process with a local resorption. Clinically, the unbalanced tissue remodelling could play a role in the convective and diffusive transports into the end plate, which is of prime importance for the segment homeostasis in scoliosis treatment with or without surgery.