Intraoperative 2D C-arm and 3D O-arm in children: a comparative phantom study.

PURPOSE: Exposure to ionizing radiation is a concern for children during intraoperative imaging. We aimed to assess the radiation exposure to the paediatric patient with 2D and 3D imaging. METHODS: To evaluate the radiation exposure, patient absorbed doses to the organs were measured in an anthropomorphic phantom representing a five-year-old child, using thermoluminescent dosimeters. For comparative purposes, organ doses were measured using a C-arm for one minute of fluoroscopy and one acquisition with an O-arm. The cone-beam was centred on the pelvis. Direct and scattered irradiations were measured and compared (Student's t-test). Skin entrance dose rates were also evaluated. RESULTS: All radiation doses were expressed in µGy. Direct radiation doses of pelvic organs were between 631.22 and 1691.87 for the O-arm and between 214.08 and 737.51 for the C-arm, and were not significant (p = 0.07). Close scattered radiation on abdominal organs were between 25.11 and 114.85 for the O-arm and between 8.03 and 55.34 for the C-arm, and were not significant (p = 0.07). Far scattered radiation doses on thorax, neck and head varied from 0.86 to 6.42 for the O-arm and from 0.04 to 3.08 for the C-arm, and were significant (p = 0.02). The dose rate at the skin entrance was 328.58 µGy.s-1 for the O-arm and 1.90 with the C-arm. CONCLUSION: During imaging of the pelvis, absorbed doses for a 3D O-arm acquisition were higher than with one minute fluoroscopy with the C-arm. Further clinical studies comparing effective doses are needed to assess ionizing risks of the intraoperative imaging systems in children.

The role of the periosteal sleeve in the reconstruction of bone defects using a non-vascularised fibula graft in the pediatric population.

BACKGROUND: Following resection of large benign bone tumors surgeons are confronted with bone defects severely affecting the stability of a limb. To restore the mechanical continuity of the bone different treatment methods using bone grafts have been described. In pediatric patients the thick periosteal sleeve is thought to contribute to bone formation. HYPOTHESIS: An intact periosteal sleeve is crucial in bone remodelling around a non-vascularised fibular graft used to bridge large bone defects. METHODS: We present a treatment technique applied in 6 cases comprising of subperiosteal tumor resection at the diaphyseal or metaphyseal level of long bones followed by defect bridging with a non-vascularised fibula graft inserted into the periosteal sleeve of the resection zone. Elastic intramedullary nails or plates were used for stabilisation. RESULTS: Due to the intact periosteum at the resection site bone integration occurred quickly and full remodelling was seen in all but one case. Tumor location in this case was at the metaphyseal level resulting in tumor resection at the growth plate. Although bone healing at the distal resection site was seen after a few weeks proximal consolidation was only partial. Full reconstitution of the fibula in the remaining periosteal sleeve was seen in 5 cases, partial reconstitution in 1 case. DISCUSSION: In the pediatric patient, the described technique is an effective and reliable treatment method for large benign bone tumors requiring resection. However, great diameter discrepancy of the donor and recipient site and a thin periosteum can be a limiting factor for its application. LEVEL OF EVIDENCE: Level IV clinical study.

Complex regional pain syndrome type I in children: What is new?

Complex regional pain syndrome type I (CRPS-I), although first described by the French surgeon Ambroise Paré as far back as the 16th century, nevertheless remains shrouded in mystery. The most common symptoms are pain in an entire hand or foot, allodynia, functional impairment induced by the pain, local oedema and skin color changes and transient sweating abnormalities. Most cases occur after a minor injury (i.e., a sprain or fracture), although there may be no identifiable triggering event, particularly in children. Primarily cold CRPS-I is by far the most common variant in children. Development of the Budapest criteria has benefited the diagnosis. These criteria are clinical and no specific diagnostic investigation is available. In vitro and in vivo studies have established that several pathogenic mechanisms can be involved concomitantly. However, there is no satisfactory explanation to the full clinical spectrum. Blood tests and imaging studies are useful for ruling out other diagnoses then monitoring the course of the condition, which may involve the development of demineralisation or osteopenia. High-resolution peripheral quantitative computed tomography may be helpful, as it provides quantitative assessments of the cortical and trabecular bone. CRPS-I has several specific characteristics in children compared to adults and whether the condition is the same entity in these two age groups is a legitimate question. The optimal management involves an early diagnosis followed by a multidisciplinary management programme of functional rehabilitation therapy and cognitive behavioral therapy. Analgesics are useful only during the phase of acute pain and to facilitate physical therapy. Studies in adults showed that bisphosphonates were effective within the first 12 months after symptom onset and calcitonin in longer-lasting cases. No high-quality clinical research studies into the aetiopathogenesis and treatment of CRPS-I in children and adolescents are available to date.

Erratum to: Resorbable osteosynthetic devices in pediatric traumatology: a prospective series of 24 cases.

Erratum to: Eur J Orthop Surg Traumatol DOI 10.1007/s00590-015-1656-8. The author would like to correct the errors in the publication of the original article. The corrected details are given below for your reading. Second and third authors' given names have been published incorrectly. The correct author names should be D. Popkov and H. Huber. The affiliations of the authors J. M. Poircuitte, D. Popkov, H. Huber, E. Polirsztok and P. Journeau are incorrect. The correct affiliations should be: J. M. Poircuitte, H. Huber, E. Polirsztok and P. Journeau: Service de chirurgie orthopedique pediatrique, Hopital d'enfant, Centre hospitalo-universitaire de Nancy, 5 allee du Morvan, 54500 Vandoeuvre les Nancy, France. D. Popkov: Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics, Kurgan, Russia. Corresponding author e-mail address should be p.journeau@ chu-nancy.fr.

Resorbable osteosynthetic devices in pediatric traumatology: a prospective series of 24 cases.

UNLABELLED: Bioresorbable devices are commonly used in traumatology. The biomechanical stability of these materials has improved in the past decade, and they have proven to be biologically non-hazardous, while their main advantage is that their use avoids reintervention for removal of the device. A prospective monocentric study was conducted: 24 patients presenting with a fracture that was amenable to osteosynthesis by small-diameter screws were included. These comprised ten tibial spine fractures, four osteochondritis dissecans of the distal femur, eight fractures of the medial epicondyle of the distal humerus, and two distal tibial apophyseal fractures. One or more screws were used that were made of a copolymer of poly-L-lactide-poly-D-lactide acid and trimethylene carbonate with a diameter of 2.8 mm. All patients were immobilized with a cast. Clinical and radiographic monitoring was conducted every month. The entire follow-up protocol had a duration of 24 months. One patient with osteochondritis dissecans presented with joint effusion. Joint stiffness at the time of cast removal resolved completely after 4 months, except for with three children (one epicondyle fracture, two tibial spine fractures). No subjective or objective instability could be detected by clinical examination. Radiographic follow-up revealed no secondary displacement, and all of the fractures had healed. No osteolysis was seen around the screws. No growth disturbances were noticed. Bioresorbable materials thus appear to be a suitable alternative approach for certain pediatric fractures. Their use resulted in outcomes similar to traditional techniques in terms of functional properties and bone healing. Although initial costs are presumably slightly higher, by avoiding a removal operation the total financial burden is most likely reduced. LEVEL OF EVIDENCE: III.

Widespread intracranial calcifications in the follow-up of a patient with cartilage-hair hypoplasia--anauxetic dysplasia spectrum disorder: a coincidental finding?

BACKGROUND/PURPOSE: Intracranial calcifications have been identified in many neurological disorders. To our knowledge, however, such findings have not been described in cartilage-hair hypoplasia - anauxetic dysplasia spectrum disorders (CHH-AD), a group of conditions characterized by a wide spectrum of clinical manifestations. METHODS/RESULTS: We report a 22-year old female patient, diagnosed with this disorder during her first year of life, and in whom bilateral intracranial calcifications (frontal lobes, basal ganglia, cerebellar dentate nuclei) were discovered by brain MRI at the age of 17 years. CONCLUSION: The etiology of this finding remains unclear. Some causes of such deposits can be of a reversible nature, thus prompting early recognition although their consequences on clinical outcome remain mostly unknown.

[Not Available]. / Traitement chirurgical initial des brûlures de la main de l'enfant. Revue.

The early management of pediatric hand burns includes surgical treatment, medical follow up and prevention of abnormal scarring by splits and/or pressure garment therapy. The aim of this review was to find the best available evidence in the literature on the surgical part of this management. This review started with a search in the PubMed database for the keywords, hand AND/OR child AND/OR burn. Only the articles published between January 1(st), 2005 and January 1(st), 2011 were selected. The data were compared to French and American textbooks. Contradictory findings were reported on the timing of the excision and graft, with only two comparative studies reported, with a lot of biases. The state of the art on the initial management of hand burns in children is not totally conclusive due to the lack of statistic power in these studies, but many expert opinions help to define options for good therapeutic paradigms. It is important to include these patients in prospective protocols with both early and long-term follow-up in order to increase the amount of evidence at our disposal.

Experimental study of progressive tibial lengthening in dogs using the Ilizarov technique. Comparison with and without associated intramedullary K-wires.

UNLABELLED: A delay in the union of bone regenerate in surgical lengthening procedures and the healing index (HI) are major factors in the quality of the results in progressive bone lengthening. Early removal of the external fixator (EF) is associated with a low rate of postoperative complications, including pin track infection, and with better muscle and joint function recovery. Addition of intramedullary wires (IMWs) to the EF led to a 9-49% decrease in the HI depending on the clinical series. We hypothesized that IMWs may accelerate the ossification process of bone regenerate and tested it in this experimental study. METHODS: Progressive tibial lengthening of 28 mm was obtained in 12 dogs operated with the classical Ilizarov technique (group I) and in 12 dogs operated with the same technique and addition of two IMWs 1.5 mm in diameter (group II). The following criteria were assessed: HI, X-ray measurements, and histological aspect of the bone regenerate and postoperative complications. RESULTS: The mean HI was 32.3% lower in group II than in group I. The radiological bone union criteria were observed on day 15 of the fixation period in group II versus day 30 in group I. Histology showed that maturation occurred earlier and bone cortices were thicker in group II than group I. Intramedullary ossification was present along the IMW in group II, whereas it was absent in group I. No clinical complications were observed in either group. DISCUSSION: The presence of the IMWs clearly contributes to stimulation of the ossification processes of the bone regenerate and to acceleration of bone union. IMWs allowed an earlier removal of the external fixator for a 32% time reduction compared to cases without IMWs. In addition, new intramedullary bone formation and presence of IMWs are expected to increase the mechanical resistance of the bone regenerate. CONCLUSION: Improvement of quantitative and qualitative criteria of bone regenerate in progressive bone lengthening with an EF combined with IMWs was demonstrated in this experimental study. SIGNIFICANCE: Favorable results encourage the authors to continue using IMWs in addition to the EF in patients treated with long-bone progressive lengthening. LEVEL OF EVIDENCE: II.

A descriptive analysis of the upper limb patterns during gait in individuals with cerebral palsy.

Patients with cerebral palsy (CP) are characterized by a large diversity of gait deviations; thus, lower limb movements during gait have been well-analyzed in the literature. However, the question of upper limb movements and, more particularly, arm movements during gait has received less attention for CP patients as a function of the disease type (Hemiplegic, HE or Diplegic, DI). Thus, the aim of this study was to investigate upper limb movements for a large group of CP patients; we used a retrospective search, including upper limb kinematic parameters and 92 CP patients (42 females and 50 males, mean±standard deviation (SD); age: 15.2±6.7 years). The diagnoses consisted of 48 HE and 44 DI. A control group of 15 subjects (7 females and 8 males, age: 18.4±8.4 years) was included in the study to provide normal gait data. For the DI patients and CG, 88 arms and 30 arms were analyzed, respectively. For the HE patients, 48 affected arms and 48 non-affected arms were analyzed. The kinematic parameters selected and analyzed were shoulder elevation angles; elbow flexion angles; thorax tilt and obliquity angles; hand vertical and anterior-posterior movements; and arm angles. Several gait parameters were also analyzed, such as the gait profile score (GPS) and normalized speed. Statistical analyses were performed to compare CG with the affected and non-affected upper limbs of HE patients and with the two upper limbs of DI patients. The results show that HE and DI patients adopt abnormal upper limb movements. However, DI patients have greater shoulder, elbow, thorax and arm angle movements compared with HE patients. However, HE patients adopt different movements between their affected and non-affected arms. Thus, the patients used their upper limbs to optimize their gait more where gait deviations were more important. These observations confirm that the upper limbs must be integrated into rehabilitation programs to improve inter-limb coordination.

Perioperative medullary complications in spinal and extra-spinal surgery in mucopolysaccharidosis: a case series of three patients.

The mucopolysaccharidoses (MPS) are genetic lysosomal storage diseases. Peripheral bone dysplasia and spinal involvement are the predominant orthopedic damage. The risk of spinal cord compression due to stenosis of the craniocervical junction is well known in these patients, whereas the thoracolumbar kyphosis is often well tolerated over a long period of time. Thus, signs of spinal cord compression at this level occur later and more insidiously. The authors describe three cases of patients with thoracolumbar kyphosis who suffered from postoperative spinal cord compression in the absence of direct surgical trauma. Analysis of these cases and review of the literature helped identify causal factors resulting in spinal cord ischemia. The risk of perioperative spinal cord complications related to a thoracolumbar kyphosis must be discussed with patients with MPS and their families prior to any surgery, including extra-spinal procedures.

[Popliteal cysts: etiologic and therapeutic approach]. / Kystes poplités: approches étiologique et thérapeutique.

In children and adults, a popliteal cyst frequently coexists with an intra-articular disorder of the knee. Its mode of presentation consists of a palpable mass at the level of the popliteal fossa. The cyst is a recess of the synovial cavity of the knee, often associated to a chronic effusion. In children, the etiology may be primary with a development directly from the medial gastrocnemius-semimembranous bursa. In adults, it is usually secondary to degenerative or inflammatory disease of the knee. A communication between the intraarticular space and the cystic cavity can be often found. The aim of this study is to review epidemiology, pathogenesis, symptomatology, diagnosis and treatment options.

The anatomical basis for anterior interosseous nerve palsy secondary to supracondylar humerus fractures in children.

INTRODUCTION: Various studies have found that 6.6 to 31% of supracondylar elbow fractures in children have nerve-related complications. One-third of these are cases of anterior interosseous nerve (AIN) palsy that usually result in a deficit of active thumb and index flexion. The goal of this cadaver study was to describe the course of the AIN to achieve a better understanding of how it may get injured. MATERIALS AND METHODS: On 35 cadaver specimens, the median nerve and its collateral branches destined to muscles were dissected at the elbow and forearm levels. The distance at which the various branches arose was measured relative to the humeral intercondylar line. Interfascicular dissection of the AIN was used to map its distribution within the median nerve. RESULTS: The AIN arises at an average of 45 mm from the humeral intercondylar line. Before emerging from the median nerve, the AIN fascicles were always found in the dorsal part of the median nerve. After emerging, the AIN was divided into two zones. Zone 1 was the transitional portion from its exit point until its entrance into the interosseous space, where it changes direction. Zone 2 was the interosseous portion between the radius and ulna that comes into contact with the anterior interosseous membrane to which it is attached over its entire length until it ends in the pronator quadratus (PQ) muscle. The muscle branches of the AIN destined for the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) muscles mostly originated in Zone 1, which is the transitional portion between the median nerve and the fixed Zone 2. The branches destined to the pronator teres (PT) and flexor carpi radialis (FCR) originating from the median nerve are more proximal and superficial. DISCUSSION: The injury mechanisms leading to selective AIN palsy secondary to supracondylar elbow fracture in children are probably the result of two factors: direct contusion of the posterior aspect of the median nerve, and thereby the AIN fascicles, by the proximal fragment; stretching of AIN in Zone 1, which has less ability to withstand stretching than the median nerve and its other branches because the AIN is fixed in Zone 2. CONCLUSION: Details about the origin and course of the AIN can explain the high percentage of AIN palsy in supracondylar elbow fractures in children. LEVEL OF EVIDENCE: Level IV. Anatomic study.

Identification of gait patterns in individuals with cerebral palsy using multiple correspondence analysis.

Great importance has been placed on the development of gait classification in cerebral palsy (CP) to assist clinicians. Nevertheless, gait classification is challenging within this group because the data is characterized by a high-dimensionality and a high-variability. Thus, the aim of this study was to analyze without a priori, a database of clinical gait analysis (CGA) of CP patients, using multiple correspondence analysis (MCA). A retrospective search, including biomechanical and clinical parameters was done between 2006 and 2012. One hundred and twenty two CP patients were included in this study (51 females and 71 males, mean age ± SD: 14.2 ± 7.5 years). Sixteen biomechanical spatio-temporal and kinematic parameters were included in the analysis. This data was transformed by a fuzzy window coding based on the distribution of each parameter in three modalities: low, average and high. Afterward, a MCA was used to associate parameters and to define classes. From this, seven most explicative gait parameters used to characterize gait of CP patients were identified: maximal hip extension, hip range, knee range, maximal knee flexion at initial contact, time of peak knee flexion, and maximal ankle dorsiflexion in stance phase and in swing phase. Moreover, four main profiles of CP patients have been defined from the multivariate approach: an apparent equinus gait group (the most similar of the control group with diplegic and hemiplegic patients with a GMFCS 1), a true equinus gait group (the youngest group with diplegic and some hemiplegic patients with a GMFCS 1), a crouch gait group (the oldest group with a majority of diplegic and rare hemiplegic patients with a GMFCS 2) and a jump knee gait group (the greatest level of global spasticity of the lower limbs with a majority of diplegic and rare hemiplegic patients with a GMFCS 2). Thus, this study showed the feasibility of the MCA in order to characterize and classify a large database of CP patients.

Vascularized proximal fibular epiphyseal transfer: two cases.

Vascularized proximal fibular epiphyseal transfer in children enables reconstruction of long-bone epiphyseal defect, while conserving axial growth potential. This technique was applied in two children for diaphyseal-epiphyseal reconstruction of the proximal humerus and distal radius respectively, using a graft vascularized only by the anterior tibial artery. There were no major complications during harvesting. Both cases showed transplant growth, of a mean 0.5cm/year. Joint function in the proximal humerus reconstruction was satisfactory, with functional range of motion. In the distal radius reconstruction, range of motion was almost zero; insufficient transplant growth induced radial club hand, requiring partial correction by progressive lengthening using an external fixator. In case of severe bone loss, fibular epiphyseal-diaphyseal graft vascularized only by the anterior tibial artery is a feasible attitude.

Analysis of segmental residual growth after progressive bone lengthening in congenital lower limb deformity.

INTRODUCTION: The issue of prognosis in limb length discrepancy in children affected by congenital abnormality remains a subject of concern. Therapeutic strategy must take length prediction into account, to adapt equalization techniques and the timing of treatment. Initial prognosis, however, may need revising after completion of one or several surgical interventions on the pathologic limb. The aim of this study was to determine the different types of growth response that a bone segment can present after progressive lengthening in case of congenital limb length discrepancy. MATERIALS AND METHODS: A series of 114 bone lengthenings with external fixator, performed in 36 girls and 50 boys with congenital lower limb length discrepancy, was retrospectively analyzed. Bone segment growth rates were measured before lengthening, during the first year after frame removal and finally over long-term follow-up, calculating the ratios of radiological bone length to the number of months between two measurements. Mean follow-up was 4.54±0.2 years. RESULTS: Changes in short- and long-term growth rate distinguished five patterns of bone behavior after lengthening, ranging from growth acceleration to total inhibition. DISCUSSION: These five residual growth patterns depended on certain factors causing acceleration or, on the contrary, slowing down of growth: age at the lengthening operation, percentage lengthening, and minimal period between two lengthenings. These criteria help optimize conditions for resumed growth after progressive segmental lengthening, avoiding conditions liable to induce slowing down or inhibition, and providing a planning aid in multi-step lengthening programs. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Classification of complications after progressive long bone lengthening: proposal for a new classification.

INTRODUCTION: Long bone lengthening surgery using progressive surgical methods has been the source of frequent complications. Some authors have classified these complications either descriptively, according to the date of onset after the operation, or based on their severity. The Caton classification (1985) has had the virtue of contributing the notion of the treatment contract stipulating the objective to reach in treatment. Within the context of the preoperative information delivered to patients and their family, this contract can be improved by adding a notion of maximum treatment duration. The objective of this study was therefore to propose a classification that includes honoring a triple contract associating the planned gain in bone length, the duration of treatment, and the occurrence of sequelae. MATERIALS AND METHODS: The classification of complications proposed includes four grades: grade I: triple contract honored, including a few treatments without general anesthesia; grade II: triple contract fulfilled, but with unplanned interventions under general anesthesia; grade III: the time stipulated was not honored because the time to obtain bone union was too long or because the program was interrupted; grade IV: sequelae are present. This classification was assessed based on a consecutive series of 34 surgical procedures in 32 patients (two patients underwent two lengthening procedures during this period) at 43 bone segments associating progressive lengthening with external fixation or with nail lengthening. The grade of each complication was determined by each of the authors according to the classification proposed and other classifications reported in the literature (Caton, Paley, Popkov, and Donnan). RESULTS: Approximately one-third (10) of the 34 lengthening procedures did not present any complications. Two-thirds (24) presented 30 complications. Consensus was obtained between all the authors on the grades proposed for our classification and the Caton classification, but consensus was not reached with the other classifications in which part of the interpretation was subjective (Paley, Popkov, and Donnan). DISCUSSION: The classification proposed required respecting predetermined objectives during limb lengthening surgery based on a triple contract: gain, duration, and function. It is reliable and reproducible by different operators because the criteria are objective. It can also be applied to diverse surgical techniques, whether with external fixation and/or internal osteosynthesis. LEVEL OF EVIDENCE: Level IV: retrospective study or historical series.

Early complications with flexible intramedullary nailing in childhood fracture: 100 cases managed with precurved tip and shaft nails.

BACKGROUND AND PURPOSE: Diaphyseal and metaphyseal fractures in children are frequently treated with the flexible intramedullary nailing (FIN) method. The aim of this study was to record postoperative complications and outcome in consecutive fracture patients treated with the new precurved tip and shaft nails and dedicated ergonomic instrumentation. METHODS: We report the analysis of 100 consecutive fractures followed up for a minimum of 6 months. Ninety-seven children were included, comprising 77 shaft and 23 metaphyseal fractures. Demographic data, duration of surgery, nail and medullary canal diameter, date of nail removal, clinical assessment, follow-up radiographs and all complications were recorded. RESULTS: Mean age was 9.7 years, and mean body weight 35.1 kg. Twenty-one fractures had associated lesions. Mean duration of surgery was 42.4 minutes. Nail removal was at a mean 6.1 months. Twelve percent of patients had complications, with six insufficient reductions, one delayed union, one non-union, one iterative fracture, and three skin impingements. Unexpected surgical revision was required in seven cases. At follow-up, only one patient showed functional impairment, with 20° pronation loss, and three showed more than 10° axial deviation on X-ray. CONCLUSION: The low rate of skin impingement compared with the literature may be due to the new dedicated instruments. We believe that other complications can be avoided if one follows the FIN principles, avoiding weak assembly due to an insufficient nail/medullary canal diameter ratio, which is a limiting factor for indications in adolescents. The surgeons reported that precurved shaft nails facilitated the FIN procedure, although this subjective judgment may be due simply to the novelty of the nails. LEVEL OF EVIDENCE: Level IV. Retrospective study.

Elastic intramedullary nailing as a complement to Ilizarov's method for forearm lengthening: a comparative pediatric prospective study.

PURPOSE: Most of the techniques for forearm lengthening involve external fixation to achieve stability and provide progressive distraction. We introduce the use of elastic stable intramedullar nailing (ESIN) in combination with external circular assembly for the procedure. The purpose of this prospective study was to compare Ilizarov's classical technique with this combined technique. METHODS: Fifty-seven patients, with forearm length discrepancies or deformities either congenital or acquired, were prospectively followed-up. Patients were divided in two groups: 35 had only external fixation, and 22 had external fixation-ESIN combined techniques. Patients were assessed for clinical and radiographic outcome with a mean follow-up of 21 months after external device removal. RESULTS: Overall lengthening was 45.0mm. Healing index (HI) was 22.2d/cm with the combined technique, and 32.0 d/cm with external fixation. HI was 30% better when ESIN was used, for congenital and for overall cases. Combined technique has a lower complication rate. CONCLUSION: Although forearm lengthening still remains a time-consuming procedure, ESIN can shorten external fixator wearing time. No additional complication occurred and bony complications seem to be limited by the nails. We recommend this technique, which we now use for most of our patients undergoing limb lengthening. LEVEL OF EVIDENCE: Level IV.

Bone bridge resection for correction of distal radial deformities after partial growth plate arrest: two cases and surgical technique.

Partial closure of the growth plate is an uncommon complication in the distal radius even though distal radial fractures are among the most common injuries in children. We report two cases of resection of a bony bridge in the distal radial growth plate in boys aged 8 and 9 years with a description of the operative technique.

Hip septic arthritis in children: assessment of treatment using needle aspiration/irrigation.

INTRODUCTION: This retrospective series evaluated the surgical treatment of hip arthritis in children by needle aspiration-irrigation alone. PATIENTS AND METHODS: Forty-three cases of septic hip arthritis were treated by needle aspiration-irrigation under general anesthesia associated with intravenous then oral administration of antibiotics. Clinical and biological criteria at admission, during hospitalization and at final follow-up were studied to identify any criteria carrying a predictive value for unsuccessful needle aspiration-irrigation. RESULTS: Thirty-eight hips had a favorable outcome in this series, while secondary open arthrotomy was required in five hips for further irrigation. Common criteria found in the group requiring open arthrotomy were a diagnosis delay of at least 6 days between initial clinical symptoms and treatment as well as markedly abnormal biological results at admission. A threshold for the predictive value of certain variables was identified including C-reactive protein above 100, white polynuclear blood count above 15000, and sedimentation rate above 25 in the first hour and 50 in the second hour. DISCUSSION: Treatment modalities for septic arthritis of the hip remain controversial in children and various techniques have been shown to be effective in the literature. Needle aspiration-drainage, the least invasive of these, has been shown to have good results, even in the hip, even though this is a deep, tight, joint which is known to be difficult to drain. Prognostic criteria are difficult to identify, however all authors agree that delayed treatment makes evacuation of intra-articular debris especially difficult. CONCLUSION: Needle aspiration-irrigation is effective in septic arthritis of the hip, as long as basic principles are followed. Delayed treatment and certain biological criteria should be taken into account when selecting a treatment, since negative predictive criteria identified in this series were present in the five hips requiring secondary arthrotomy.