Does arthroscopic resection of a too-long anterior process improve static disorders of the foot in children and adolescents?

PURPOSE: A too-long anterior process of the calcaneus is a common cause of pain and hind-foot instability. Our goal was to evaluate the early results of arthroscopic resection in terms of static foot disorders in children and adolescents. METHODS: We retrospectively studied 11 ft (10 patients). The inclusion criteria were treatment of TLAP by arthroscopic resection and a minimum follow-up period of six months. Surgery was indicated in cases with persistent symptomatic TLAP resistant to orthopaedic treatment. RESULTS: The mean age at surgery was 11 (range, 7-15) years. The mean follow-up duration was 15 (range, 8-28) months. Pre-operatively, we diagnosed four flat feet, two cavus feet and five feet with normal footprints, but loss of physiological hind-foot valgus. All patients presented with subtalar joint stiffness. At the last follow-up, four feet with no hind-foot valgus were normal, two were unchanged and the other feet had improved. The mean AOFAS increased from 61.9 (range, 47-73) to 89.1 (range, 71-97; P = 0.009). The mean radiological angles were near normal, exhibiting significant improvements in the lateral talo-metatarsal and Djian-Annonier angles. CONCLUSIONS: Arthroscopic resection of a TLAP is safe. In the short term, the restoration of subtalar mobility reduces pain, and improves instability and static disorders. Longer follow-up of a larger patient series is required.

Closed reduction by trans-physealantegrade elastic stable intramedullary nailing in acute pediatric Monteggia fractures: a report of 22 cases.

Treatment of acute pediatric Monteggia fractures is still debated. The aim of this study was to assess the efficacy of strategy based on closed reduction by trans-physeal antegrade elastic stable intramedullary nailing (ESIN) of the ulnar fracture. Retrospective analysis of 22 patients (13 boys and nine girls) treated for acute Monteggia fractures between May 2008 and August 2018 was performed. Mean age at injury was 6.6 years. Mean follow-up was 4.5 years. On the basis of the Bado classification, 15 lesions were of type I, three types III and four types IV. All the patients were managed with closed reduction and ESIN of the ulna fracture within 2-19 h of arrival. Intraoperative stability of reduction of the radial head was checked under fluoroscopic control in pronation and supination. Outcomes were assessed with the Bruce et al. scoring system. Closed alignment of the ulnar fracture by ESIN had simultaneously reduced and stabilized the radial head dislocation in all patients. At the final follow-up, all the patients had excellent results. Complete healing of the fracture occurred in 6 weeks and the elastic nail removed at 3-6 months postoperatively. There was no case of instability or subluxation or re-dislocation of the radial head. No olecranon epiphysiodesis or growth disorders were noticed. Early diagnosis and management of acute pediatric Monteggia fractures by closed reduction and ESIN achieve excellent clinical and radiographic outcomes.

Is there a persistent capital femoral epiphysis growth after screw fixation for slipped capital femoral epiphysis?

Femoral neck screwing during child development is controversial. The objective of this study was to evaluate the residual growth of the capital femoral physis after screw fixation. This retrospective study included children aged younger than 12 years treated for slipped capital femoral epiphysis (SCFE) with a single percutaneous partially threaded cannulated screw. The children were followed up for at least 1 year. Some patients also underwent prophylactic contralateral screwing. Preoperative, immediate postoperative and final follow-up X-rays were evaluated to determine the degree of slippage, pin-joint ratio (PJR), neck-pin ratio (NPR), number of threads crossing the physis, neck-shaft angle (NSA), screw-physis angle and screw position in the physis. We included 17 patients (29 hips: 18 SCFE and 11 prophylactic) with a mean age of 10.1 years (range: 7.1-11.9 years) at the time of surgery. Significant evolution of radiological growth parameters of the proximal femoral physis was noted during a mean follow-up of 2.4 years (range: 1-4.3 years). The mean PJR significantly decreased from 7.3 to 6.0, the mean NPR significantly decreased from 106 to 96 and the mean number of threads beyond the physis decreased from 3.3 to 1.8. The mean NSA decreased by 6.5°, from 139° to 132.5°. Persistent capital femoral epiphysis growth occurs after screw fixation. The NSA significantly decreases over time but remains within the physiological limits. Level of evidence: IV (case series).

Minimally invasive treatment of aneurysmal bone cysts: Systematic literature review.

INTRODUCTION: The optimal treatment of aneurysmal bone cysts (ABC) remains controversial. Surgery has long been considered as the treatment that yields the best outcomes. Some authors now prefer using less invasive options as the primary treatment. The primary objective of this systematic literature review was to determine if treatments that are less invasive than surgery are also effective in curing the ABC. The secondary objective was to determine the respective role of each treatment in the therapeutic arsenal. HYPOTHESIS: Less invasive treatments can replace surgery as the base treatment for ABC. PATIENTS AND METHODS: A PubMed® search was carried out for this review. The inclusion criteria were ABC treatment without cyst removal, case series, clinical case reports, reviews, publication in French or English. Excluded were articles that described the results of surgical treatment only, cranial or maxillofacial cysts, secondary ABC, duplicates, no abstract available. Based on the first six items of the "MINOR criteria", we selected 42 studies. For each selected study, we analyzed the number of cases, clinical response to treatment, radiological healing, recurrence or failure rate, complications and side effects of the treatment. RESULTS: This review found that less invasive treatments generate results that are at least as good as surgery, often with fewer complications. Thus, in certain cases, these treatments can be recommended as first-line therapy. This category includes selective arterial embolization, sclerotherapy (alcohol, polidocanol) and injection of demineralized bone matrix. DISCUSSION: Selective arterial embolization yields good results. While this is a difficult, operator-dependent technique that is not suitable for all ABCs (no identifiable feeding vessel), we recommend it as the primary treatment for spinal ABCs. For ABCs in other locations, sclerotherapy can be used as the primary treatment. However, this treatment becomes inconvenient if the number of injections is too high. Radiation therapy is not a first-line treatment because of its side effects. Bisphosphonates and denosumab can be used when the other treatments are contraindicated.

Can objective criteria for poor tolerance of proximal humerus malunion be identified?

BACKGROUND: Malunion of the proximal humerus is common and variably tolerated. Classifications developed for proximal humerus malunion (PHM) rely on standard radiographs, which underestimate bone fragment displacement and lack accuracy. The clinical tolerance of PHM is subjective, and revision surgery is not always necessary. The primary objective of this study was to assess the reproducibility and relevance of four CT angle measurements for objectively quantifying the morphological disharmony caused by PHM in a control population then in a population with PHM. The secondary objectives were to identify angle cut-offs and to assess the correlations between angle values and the clinical tolerance of PHM. HYPOTHESIS: Objective criteria for assessing proximal humerus malunion can be identified using CT scans. MATERIALS AND METHODS: Four angles were chosen to quantify proximal humerus disharmony: the angles between the humeral head and the glenoid in the coronal plane (HGCo) and axial plane (HGAx), the angle of tuberosity divergence in the axial plane (TDAx), and the centrum collum diaphyseal angle (CCD). The reproducibility of measurements of the four angles on computed tomography (CT) views was evaluated in a control population and in 46 patients with PHM. To this end, the reproducibility of reference slice selection was determined and intra- and interobserver reproducibility of the angle measurements was then assessed. Patients with PHM were divided into two groups based on clinical tolerance to allow testing for disharmony parameters associated with poor clinical tolerance, which was defined as functional impairment and surgical revision. RESULTS: Slice selection was found to be reproducible. The Bland-Altman plot indicated that the angle measurements in both the controls and the patients were reproducible within ±2 SDs. Intraclass correlation coefficient values ranged from fair to excellent for all angles in both the controls and the patients. The mean TDAx was higher in the patients than in the controls (72.0° vs. 56.1°, P<0.05) and, within the PHM group, was higher in the subgroup with good vs. poor clinical tolerance (75.8° vs. 69.5°, P<0.05). The CCD angle was greater in the controls than in the patients (129.8° [range, 128.3°-131.3°] vs. 125.9° [range, 122.9°-128.9], respectively) and was significantly greater in the PHM subgroup with good vs poor clinical tolerance (131.4° vs. 122.3°, respectively; P=0.007). The HGCo and HGAx angles were significantly greater in the patients than in the controls (HGCo: 66.6° vs. 52.2°, respectively; HGAx: 17.5° vs. 13.3°, respectively, P=0.55). DISCUSSION: The measurement method described here provides a quantitative assessment of postfracture disharmony based on four angles, the HGCo, HGAx, and TDAx. Measurement of these four angles on CT images was found to have good intra- and interobserver reproducibility. The angle values were significantly greater in the patients with PHM than in the controls. Within the patient group, the subgroup with poor clinical tolerance had smaller values of the TDAx, CCD, and HGAx angles and a greater value of the HGCo angle. LEVEL OF EVIDENCE: IV, retrospective observational study.

Synovial-Fluid miRNA Signature for Diagnosis of Juvenile Idiopathic Arthritis.

Juvenile idiopathic arthritis (JIA) is the most common chronic inflammatory rheumatism in childhood; microRNAs (miRNAs) have been proposed as diagnostic biomarkers. Although joints are the primary targets for JIA, a synovial fluid-based miRNA signature has never been studied. We aim to identify miRNA biomarkers in JIA by comparing synovial fluid and serum samples from children with JIA and K.kingae septic arthritis (SA). With next-generation high-throughput sequencing, we measured the absolute levels of 2083 miRNAs in synovial fluid and serum from an exploratory cohort of children and validated differentially expressed miRNAs in a replication study by using RT-qPCR. We identified a 19-miRNA signature only in synovial fluid samples that was significantly deregulated, with at least 2-fold change in expression, in JIA versus SA (p < 0.01). The combination of miR-6764-5p, miR-155, and miR-146a-5p expression in synovial fluid yielded an area under the receiver operating characteristic curve of 1 (95% CI 0.978 to 1), thereby perfectly differentiating JIA from SA in children. We propose, for the first time, a synovial fluid-specific miRNA signature for JIA and associated signaling pathways that may indicate potential biomarkers to assist in the classification and differential diagnosis of JIA and help in understanding JIA pathogenesis.