Fingertip nail bed injuries in children: Comparison of suture repair versus glue (2-octylcyanoacrylate) with 1-year follow-up.

The main objective of this study was to compare the medium-term results of nail bed repair in children using glue (2-octylcyanoacrylate) versus absorbable sutures. The secondary objective was to compare the results of treatment in the emergency room versus the operating room. This retrospective review of 74 fingertip nail bed lacerations (68 children) evaluated the appearance and pain at the last follow-up visit (minimum of 1 year), and the operating time. Mean age was 3.3 years at time of injury (range 10 months-13 years), with a mean follow-up of 2.6 (1-7) years. Thirty-six nail beds were repaired with glue; 38 were sutured. The clinical outcomes in the two groups were similar. The rate of nail dystrophy was 14% (5% major) regardless of the technique. Nail bed repair time was significantly shorter in the glue group (10.2 vs. 20.3min, p<0.001). Forty-five repairs were performed in the operating room and 29 in the emergency room. The complication rate (early infections) was significantly higher in patients treated in the emergency room. Tissue adhesive (2-octylcyanoacrylate glue) is a reliable option for repairing nail bed lacerations, both in terms of outcomes and speed of repair. Treatment in the operating room is preferable.

Effects of marine noise pollution on Mediterranean fishes and invertebrates: A review.

Marine noise pollution (MNP) can cause a multitude of impacts on many organisms, but information is often scattered and general outcomes difficult to assess. We have reviewed the literature on MNP impacts on Mediterranean fish and invertebrates. Both chronic and acute MNP produced by various human activities - e.g. maritime traffic, pile driving, air guns - were found to cause detectable effects on intra-specific communication, vital processes, physiology, behavioral patterns, health status and survival. These effects on individuals can extend to inducing population- and ecosystem-wide alterations, especially when MNP impacts functionally important species, such as keystone predators and habitat forming species. Curbing the threats of MNP in the Mediterranean Sea is a challenging task, but a variety of measures could be adopted to mitigate MNP impacts. Successful measures will require more accurate information on impacts and that effective management of MNP really becomes a priority in the policy makers' agenda.

Median Nerve Entrapment after Supracondylar Humeral Fracture in a Young Child.

Median nerve entrapment after supracondylar humeral fracture in children is rare. We report a case of Gartland type III supracondylar humeral fracture complicated by an entrapment of the median nerve following closed reduction and percutaneous pinning in a 5-year-old child. The diagnosis of entrapment was made 14 months post injury following progressive motor and sensory palsy. Resection and end-to-end suture were performed, leading to complete sensory and motor recovery eight months later. This nerve complication is often unnoticed and should be suspected systematically before and after reduction of all displaced supracondylar humeral fracture in children. The indication of resection-suture or nerve graft depends on the entrapment and the delay of the palsy.

Short-course antibiotic treatment of bone and joint infections in children: a retrospective study at Montpellier University Hospital from 2009 to 2013.

BACKGROUND: Acute haematogenous bone and joint infections (AHBJI) represent a diagnostic and therapeutic emergency in children, with significant potential sequelae in the case of delayed treatment. Although historically the recommendations for treatment have been based on surgery and prolonged antibiotic therapy, recent studies have demonstrated that short-course antibiotic therapy is also effective. OBJECTIVES: We evaluated a short-term antibiotic protocol for both osteomyelitis and septic arthritis in a 6 year retrospective study at the University Hospital of Montpellier. METHODS: This protocol was based on an initial intravenous treatment with a re-evaluation after 48 h and an early switch to oral therapy in the case of a favourable clinical course for a minimum total duration of 15 days. Antibiotics were selected based on local microbiological epidemiology and systematically adapted to bacteriological results. RESULTS: One hundred and seventy-six cases of AHBJI were included, comprising 56 patients with osteomyelitis, 95 with septic arthritis and 25 who had both of these. The aetiological agent was identified in 42% of the cases, with the main pathogens being Staphylococcus aureus (39%) and Kingella kingae (27%). The mean intravenous treatment duration was 4 days, while the total treatment duration was 15 days. There were no treatment failures, mild sequelae occurred in 1% of the cases and the secondary surgical revision rate was 7%. CONCLUSIONS: The results of this study are comparable to those reported for evaluations of prolonged antibiotic therapy protocols, thus indicating that a common short-term antimicrobial therapy for the management of both osteomyelitis and septic arthritis (minimum of 15 days) is a viable option for treating AHBJI in children. Further prospective studies to confirm these findings are hence warranted.

Performance of genotypic algorithms for predicting tropism for HIV-1 CRF01_AE recombinant.

OBJECTIVES: There is no consensus about the performances of genotypic rules for predicting HIV-1 non-B subtype tropism. Three genotypic methods were compared for CRF01_AE HIV-1 tropism determination. METHODS: The V3 env region of 207 HIV-1 CRF01_AE and 178 B subtypes from 17 centers in France and 1 center in Switzerland was sequenced. Tropism was determined by Geno2Pheno algorithm with false positive rate (FPR) 5% or 10%, the 11/25 rule or the combined criteria of the 11/25, net charge rule and NXT/S mutations. RESULTS: Overall, 72.5%, 59.4%, 86.0%, 90.8% of the 207 HIV-1 CRF01_AE were R5-tropic viruses determined by Geno2pheno FPR5%, Geno2pheno FPR10%, the combined criteria and the 11/25 rule, respectively. A concordance of 82.6% was observed between Geno2pheno FPR5% and the combined criteria for CRF01_AE. The results were nearly similar for the comparison between Geno2pheno FPR5% and the 11/25 rule. More mismatches were observed when Geno2pheno was used with the FPR10%. Neither HIV viral load, nor current or nadir CD4 was associated with the discordance rate between the different algorithms. CONCLUSION: Geno2pheno predicted more X4-tropic viruses for this set of CRF01_AE sequences than the combined criteria or the 11/25 rule alone. For a conservative approach, Geno2pheno FPR5% seems to be a good compromise to predict CRF01_AE tropism.

Monteggia injuries.

The Monteggia injury is defined as radial head dislocation with a fracture of the ulnar shaft. This combination should be sought routinely in patients with ulnar fractures, even when the displacement is small. The emergent management is simple, as reducing the ulnar fracture is usually sufficient to stabilise the radial head. Internal fixation of the ulna deserves to be widely used to fully stabilise the radial head. Irreducibility of the radial head at the acute stage may indicate an interposition, which requires open surgery on the joint. Radial head dislocation may occur even with minimal displacement of the ulnar fragment. Chronic Monteggia fractures are more challenging to treat and their outcomes are more variable. The radial head becomes irreducible after 2 to 3 weeks. When a simple surgical approach fails to ensure stable reduction, the most widely used method at present is open reduction of the radial head and proximal osteotomy of the ulnar shaft. Stability must be obtained intra-operatively. Without treatment, radial head dislocation may be well tolerated for several months or even years. In the long term, however, osteoarticular remodelling results in loss of joint congruence, pain and, eventually, osteoarthritis. Radiographs must therefore be obtained on an emergency basis and analysed with great care to avoid missing a Monteggia fracture.

A decreasing CD4/CD8 ratio over time and lower CSF-penetrating antiretroviral regimens are associated with a higher risk of neurocognitive deterioration, independently of viral replication.

Persistent immune activation is one of the suspected causes of HIV-associated neurocognitive disorders (HAND) in cART era. The CD4/CD8 ratio has been recently showed as a marker of immune activation and HAND. Our aim was to analyze if a decrease in the CD4/CD8 ratio over time could have an impact on neurocognitive deterioration. Randomly selected HIV-infected patients were followed for neuropsychological (NP) testing during a period of almost 2 years. Tests were adjusted for age, gender, and education. Patients were divided into 5 groups: normal tests (NT), neuropsychological deficit (ND, one impaired cognitive domain), asymptomatic neurocognitive disorders (ANI), mild neurocognitive disorders (MND), and HIV-associated dementia (HAD). Risk factors for neurocognitive deterioration were analyzed. Two hundred fifty-six patients underwent NP tests and 94 participated in the follow-up. The groups were comparable. Upon neuropsychological re-testing, six patients showed clinical improvement, 30 had worsened, and 58 were stable, resulting in 42 patients presenting with HAND (45 %). The majority of HAND cases consisted of ANI (26 %) and MND (16 %). In patients whose NP performance worsened, CPE 2010 score was lower at inclusion (7.13 vs 8.00, p = 0.003) and CD4/CD8 decrease more frequent (60 vs 31 %, p = 0.008) than in those who were stable or improved. Multivariate analysis confirmed these results. A decreasing CD4/CD8 ratio during a longitudinal follow-up of randomly selected HIV-infected patients and lower CSF-penetrating regimens were independently associated with cognitive decline. Monitoring trends in CD4/CD8 ratio could contribute to identifying patients at higher risk of neurocognitive deterioration.

[Exercise therapy in the treatment of idiopathic adolescent scoliosis: Is it useful?]. / La kinésithérapie dans le traitement de la scoliose idiopathique de l'adolescent : utile ou pas ?

Many practitioners, pediatricians, and general practitioners prescribe physical therapy when tracking scoliosis. However, has physical therapy alone proved its efficacy in the care of the scoliosis to slow down progression? Our purpose is to report the results of a literature review on the effectiveness of rehabilitation in idiopathic scoliosis. No current study presents sufficient scientific proof to validate the efficacy of isolated exercise therapy in scoliosis. Learned societies recognize, however, the efficacy of combining conservative therapy (brace+physiotherapy) in idiopathic scoliosis. Should we then still prescribe rehabilitation without brace treatment? Although physical therapy alone does not seem effective in treating scoliosis, it can limit potential painful phenomena and be beneficial for respiratory function. The physical therapist can also teach the teenager the classic principles of hygiene of the back. It may therefore be appropriate to prescribe physical therapy, but the principles and objectives must be explained to the patient and family in light of current evidence-based medicine.

Acute ischemia and pink pulseless hand in 68 of 404 gartland type III supracondylar humeral fractures in children: Urgent management and therapeutic consensus.

UNLABELLED: No consensus exists regarding pulseless otherwise well-perfused hand in pediatric Gartland type III fractures. The purpose of this retrospective study was to describe our strategy and to determine the guidelines of therapeutic consensus. PATIENTS AND METHODS: 404 children were treated for a type III supracondylar humeral fracture. Extension fractures-induced acute vascular injuries were noticed in 68 patients and nerve injuries were associated in 32 of them. The radial pulse was absent in all patients with two clinical situations at the initial presentation: well-perfused hand with 'pink and warm' hand in 63 patients and ischemia with 'white and cold' hand in five. Urgent closed reduction of the fracture and stabilization were performed in 63 patients with pink pulseless hand, and immediate surgical exploration in the five patients with ischemia. RESULTS: 63 patients with vascular injury had posterolateral displacement and 5 had posteromedial displacement. Sixty-three of 68 patients had posterolateral displacement of whom 28 had concomitant median nerve injury and 4 had a deficit to both median and ulnar nerves. The palpable radial pulse was immediately restored in 42 patients and between few hours to eleven days later in eighteen. Three patients with ischemia after unsuccessful reduction required immediate surgical exploration revealing incarceration of the brachial artery at the fracture site. Release and decompression of the brachial artery restored a normal limb perfusion. The five patients with primary ischemia underwent immediate open exploration and vascular repair. One of them had a compartment syndrome and required anterior fasciotomy. The restoration of blood flow with palpable radial pulse was observed in all patients. Full spontaneous nerve recovery was observed in all patients. At an average follow-up of 8.4 years, all patients had normal circulatory status, including a palpable radial pulse. DISCUSSION: This study highlighted the reliability of non invasive strategy with good outcomes. We recommend urgent closed reduction of fracture. Close observation and monitoring is mandatory if pulseless hand remains warm and well-perfused. If the patients develop blood circulation disturbances or compartment syndrome following closed reduction, immediate vascular exploration is recommend.

Mosaicplasty for femoral osteochondritis dissecans.

The authors describe a surgical mosaicplasty technique, with an anterior surgical dislocation approach without trochanterotomy, for osteochondritis dissecans of the hip. A graft was taken from the lateral condyle of the knee. Two adolescents underwent this procedure with good results. No osteonecrosis was observed at the longest follow-up. Mosaicplasty is a useful treatment method for small osteochondritis dissecans (<2cm(2)).

Virologically suppressed patients with asymptomatic and symptomatic HIV-associated neurocognitive disorders do not display the same pattern of immune activation.

OBJECTIVES: Inversion of the CD4:CD8 ratio is a marker of immune activation and age-associated disease. We measured the CD4:CD8 ratio as a marker of cognitive impairment in HIV-infected patients and explored differences according to clinical severity. METHODS: Post hoc analysis of data from two prospective cohorts of HIV-infected patients randomly selected to undergo neuropsychological tests was performed. Test scores were adjusted for age, gender and education. Inclusion criteria were undetectable viral load and stable treatment for at least 6 months. Subjects with HIV-associated dementia were excluded. Patients were divided into an unimpaired group, a group with asymptomatic neurocognitive disorder (ANI) and a group with symptomatic HIV-associated neurocognitive disorder (sHAND), represented by mild neurocognitive disorder (MND). Demographic and background parameters, immune activation markers and the CD4:CD8 ratio were recorded. RESULTS: Two hundred patients were included in the study. The mean age was 52 years, 78% were male, the mean CD4 count was 624 cells/µL, the mean nadir CD4 count was 240 cells/µL, 27% were hepatitis C virus (HCV)-coinfected, the mean duration of HIV infection was 16 years, and the mean time on current combination antiretroviral therapy (cART) was 2.9 years. Twenty-nine per cent of subjects had HAND (21% had ANI and 8% had MND). In multivariate analysis, a CD4:CD8 ratio < 1 was associated with a nadir CD4 count < 200 cells/µL [odds ratio (OR) 3.68] and with the presence of CD4(+) CD38(+) HLA(+) cells (OR 1.23). Multinominal logistic regression showed that, in comparison with the unimpaired group, diagnosis of sHAND was associated with a CD4:CD8 ratio < 1 (OR 10.62), longer HIV infection (OR 1.15) and longer current cART (OR 1.34), while the ANI group differed from the unimpaired group only for education level. CONCLUSIONS: Aviraemic patients with sHAND did not display the same pattern of immune activation as subjects with ANI, suggesting that the underlying pathophysiological mechanisms could be different.

Diagnosis and surgical treatment of dysplasia epiphysealis hemimelica. A report of nine cases.

BACKGROUND: Dysplasia epiphysealis hemimelica (DEH) is a rare developmental bone disorder with hemimelic involvement of one or more epiphysis. We report on nine new cases and discuss the clinical manifestations, the value of MRI, and the results of complete and early surgical resection of these lesions. MATERIALS AND METHODS: In this retrospective study, nine patients with a diagnosis of DEH were evaluated. Age at presentation ranged from 1 year to 12 years. The main complaint at diagnosis was a swelling bony mass. Angular deformities were recorded in two patients. All patients were surgically treated and followed up clinically and by imaging. Eight patients underwent excision only. RESULTS: The average follow-up was 5.6 years (range, 2-10.5 years). All patients had a good outcome without related symptoms. No epiphysiodesis, angular deformity or recurrence was observed. One patient with femoral lesion involving the distal medial part of the epiphysis developed, four months after surgical excision, a calcification outside the area of total excision. This calcification did not increase in size at two years follow-up. Another patient with lateral involvement of the proximal tibial epiphysis presented a postoperative nervous complication. Spontaneous nervous recovery occurred three months after surgery. DISCUSSION: MRI was useful to find a potential plane of cleavage between the epiphysis and the pathological tissue. We recommend early removing ossifications when a cleavage plane is identified. Waiting a possible complication or increasing of size does not seem logical. Of course, the treatment will be not the same if no cleavage plane is found on MRI. LEVEL OF EVIDENCE: IV.

Proximal ulnar osteotomy in the treatment of neglected childhood Monteggia lesion.

INTRODUCTION: The aim of our study was to analyze medium and long-term results of proximal ulnar osteotomy with and without ligament injury in neglected Monteggia injury in children. MATERIAL AND METHODS: This retrospective, multicenter study included 28 patients. Clinical criteria concerned the range of motion, pain and MEPI score, and radiologic criteria comprised of Storen line, head-neck ratio, radial neck angle, and signs of osteoarthritic remodeling. RESULTS: Twenty-eight patients were reviewed, at a mean 6 years' follow-up (range, 2-34y). Sixteen had proximal ulnar osteotomy without ligament reconstruction, and 12 had associated ligamentoplasty. Both groups showed significant clinical and radiological improvement, with no significant difference. Patients operated within less than 1 year had better clinical and radiographic results. There was no correlation between age at surgery and quality of results. The 5 patients who underwent condyloradial pinning showed early recurrence of dislocation and osteoarthritic remodeling. The three cases of Bado type-3 lesion had early recurrence of dislocation. DISCUSSION: Proximal ulnar osteotomy gives good long-term results in Bado type-1 lesions, regardless of age, if performed before 1 year, in the absence of osteoarthritic remodeling. Associated ligamentoplasty does not seem to be useful. LEVEL OF EVIDENCE: IV (retrospective).

[GACI syndrome: a case report with a neonatal beginning]. / Le syndrome GACI : à propos d'une observation à début néonatal.

GACI (generalized arterial calcification of infancy) is a rare autosomal recessive disorder characterized by arterial and periarticular calcifications. Most children die in the first months of life of cardiovascular complications. Hypophosphatemic rickets (HR) resistant to medical treatment may complete the phenotype and is associated with a milder phenotype. This report discusses the case of a girl who presented neonatal ectopic periarticular calcifications with spontaneous regression, and then at the age of 3 years developed HR. There was no clinical improvement after treatment with calcitriol and phosphate, and correction of alkaline phosphatase induced the recurrence of periarticular and tissular calcifications : the treatment was reduced and the bone distortion treated by surgery. GACI diagnosis was confirmed by genetic analysis. At the age of 4.5 years, she developed a retinal abnormality and decreased radial pulse: these clinical signs are usually observed in pseudoxanthoma elasticum (PXE). It is now established that GACI and PXE belong to the same entity characterized by arterial and tissular calcifications of which this original case report is an illustration.

An undetectable polymerase chain reaction signal in routine HIV plasma viral load monitoring is associated with better virological outcomes in patients receiving highly active antiretroviral therapy.

OBJECTIVES: The aim of the study was to assess whether patients with undetectable viraemia [a negative polymerase chain reaction result (PCR(neg) )] and those with plasma viral load (PVL) < 40 HIV-1 RNA copies/mL but a detectable (positive) PCR signal (PCR(pos) ) had different outcomes in terms of the development of blips and virological failure (VF). METHODS: A multicentre observational database analysis was carried out. Data for patients whose highly active antiretroviral therapy (HAART) regime had been unchanged for ≥ 6 months by 1 January 2008, whose first two PVL measurements of 2008 were < 40 copies/mL and who had at least five PVL measurements between 1 January 2008 and 31 December 2010 were extracted from a multicentre observational database of 4928 patients receiving HAART. PVL assays used during this period had a detection threshold of 20 or 40 copies/mL. Undetectable PVL at baseline (BL PCR(neg) ) was defined as PCR(neg) at the first two PVL determinations of 2008. Multivariable Cox regression analysis was performed to investigate factors associated with the occurrence of blips and VF, defined as two consecutive PVL measurements > 40 copies/mL. RESULTS: Of the 1957 patients included in the study (mean age 47 years; median antiretroviral exposure 10.3 years), 1312 had BL PCR(neg) . Outcome events included 322 blips and 139 VFs, with incidence rates being significantly lower in patients with BL PCR(neg) than in those with BL PCR(pos) [13.0% vs. 23.4% (P < 0.0001) and 5.1% vs. 11.2% (P < 0.0001), respectively]. In multivariable analysis, BL PCR(neg) was associated with a reduced risk of blips [hazard ratio (HR) 0.58; 95% confidence interval (CI) 0.47-0.73; P < 0.0001] and VF (HR 0.44; 95% CI 0.31-0.62; P < 0.0001). CONCLUSIONS: Patients with PCR(neg) had better virological outcomes than those with PVL < 40 copies/mL but detectable viraemia. This suggests that the 'no-signal' information provided by currently commercially available HIV RNA quantification assays should be used routinely.

Induced-membrane femur reconstruction after resection of bone malignancies: three cases of massive graft resorption in children.

Bone reconstruction after surgical resection of bone malignancies in children remains a difficult challenge. Induced-membrane reconstruction as described by Masquelet et al. was originally reported in traumatic or septic bone defects and is now adapted to this field. We report here three cases of massive femoral graft resorption requiring surgical revision in two boys aged 3 and 6 years and a 9-year-old girl. Hypotheses include the long delay between the two stages, nature of the bone graft, high varus loads specific to this location, and lack of stability of the fixation. This technique has recently provided promising preliminary results when applied to the field of bone tumours. However, reconstruction of the femur seems to be specifically associated with a risk of graft resorption. Identification of the origin of this major complication is needed to amend the technique or its indications.

Proximal femoral osteotomies in children.

The aim of proximal femoral osteotomies (PFO) in children is to restore normal anatomy and optimal joint congruency to prevent medium and long-terms degenerative deterioration of the hip. They play an important role in the treatment of neurological subluxations or dislocations of the hip. Advances in modern imaging and surgical techniques have improved understanding of the anatomical factors associated with a number of disorders of the growing hip and their sequelae. The indications for isolated PFO or associated with other intra- or extraarticular procedures have become more rational and better adapted to the various architectural defects and the femoroacetabular impingements. Two types of osteotomies are described: intertrochanteric osteotomies (varus and valgus correction, valgisation, flexion, extension), and osteotomies of the greater trochanter, either simple or double with lengthening of the femoral neck. Primary stability of the osteosynthesis is the major problem, as it is often affected by osteopenia. The development of new implants (LCP plate) avoids this inconvenience, resulting in geometrically precise osteotomies and a more stable fixation. Even when it is correctly performed, articular congruence is not always managed by PFO alone, it is sometimes necessary to associate acetabular procedures.

Neuro-orthopaedic evaluation of children and adolescents: a simplified algorithm.

Orthopaedic surgeons are often the first physicians to evaluate paediatric patients in the event of delayed walking, gait abnormalities, or parental concern about motor abilities. Therefore, orthopaedic surgeons must be thoroughly familiar with the normal neurodevelopmental stages. Neurological disorders are often first recognised during an orthopaedic evaluation. Minimal neurological abnormalities should be taken as warning signs that require additional investigations. Consequently, the evaluation must follow a strict protocol, even in children referred for apparently trivial functional disorders. We have developed an original physical examination protocol in which the largest possible number of signs is sought in each body position to ensure that the examination is both systematic and rapid. About ten minutes are required when all findings are normal. This protocol is extremely helpful for identifying the cause of the problem that motivated the evaluation or for reassuring the child and family. The main causes of paediatric orthopaedic disorders are cerebral palsy, spinal dysraphism, myopathies, peripheral neuropathies, motor neuron diseases, and intraspinal tumours. In some instances, no definitive diagnosis can be established clinically. In this situation, appropriate orthopaedic treatment can be initiated, although considerable caution is in order when establishing the indications. The cause may be detected only much later, when the clinical manifestations become more prominent.