Surgical management of proximal femoral unicameral bone cyst in children.

Aims: The aim of this study is to evaluate the surgical treatment with the best healing rate for patients with proximal femoral unicameral bone cysts (UBCs) after initial surgery, and to determine which procedure has the lowest adverse event burden during follow-up. Methods: This multicentre retrospective study was conducted in 20 tertiary paediatric hospitals in France, Belgium, and Switzerland, and included patients aged < 16 years admitted for UBC treatment in the proximal femur from January 1995 to December 2017. UBCs were divided into seven groups based on the index treatment, which included elastic stable intramedullary nail (ESIN) insertion with or without percutaneous injection or grafting, percutaneous injection alone, curettage and grafting alone, and insertion of other orthopaedic hardware with or without curettage. Results: A total of 201 patients were included in the study. The mean age at diagnosis was 8.7 years (SD 3.9); 77% (n = 156) were male. The mean follow-up was 9.4 years (SD 3.9). ESIN insertion without complementary procedure had a 67% UBC healing rate after the first operation (vs 30% with percutaneous injection alone (p = 0.027), 43% with curettage and grafting (p = 0.064), and 21% with insertion of other hardware combined with curettage (p < 0.001) or 36% alone (p = 0.014)). ESIN insertion with percutaneous injection presented a 79% healing rate, higher than percutaneous injection alone (p = 0.017), curettage and grafting (p = 0.028), and insertion of other hardware combined with curettage (p < 0.001) or alone (p = 0.014). Patients who underwent ESIN insertion with curettage had a 53% healing rate, higher than insertion of other hardware combined with curettage (p = 0.009). The overall rate of postoperative complications was 25% and did not differ between groups (p = 0.228). A total of 32 limb length discrepancies were identified. Conclusion: ESIN insertion, either alone or combined with percutaneous injection or curettage and grafting, may offer higher healing rates than other operative procedures. Limb length discrepancy remains a major concern, and might be partly explained by the cyst's location and the consequence of surgery. Therefore, providing information about this risk is crucial.

Clinical experience and complications with limited pleural dissection combined with a novel, simplified technique for thoracic Redon-like drain in vertebral body tethering.

PURPOSE: To report on our experience with a simplified, suction-bottle-drain technique of thoracic drain (Redon-like) combined with fully thoracoscopic vertebral body tethering (VBT) and a limited pleural approach, with particular focus on the rate of pulmonary complications. METHODS: A retrospective study was performed on all consecutive patients who underwent VBT for adolescent idiopathic scoliosis. For all subjects, a 10G Redon drain, an active drain system consisting of a perforated tube and a suction bottle, was placed intrathoracically and tunneled under the skin. All drains were removed on the first postoperative day. Perioperative and postoperative data such as type of access, length of surgery, amount of fluid collection in the drain, and length of hospital stay were collected. The type and number of pulmonary complications occurring in the first 3 months after surgery, along with their symptoms and management, were recorded. RESULTS: One Hundred eighty-two patients were included in the analysis. The mean length of surgery was 97 min (75-120). The average fluid collection in the drain was 30 ml (5-50), the mean length of hospital stay was 3 days (2-4). During the observation period, pulmonary complications occurred in five patients (2%). Two patients presented an aseptic right pleural effusion; for two patients, a residual pneumothorax was diagnosed on the X-rays in the recovery room and one patient developed a chylothorax. All patients recovered without sequelae. CONCLUSION: The simplified, Redon-like drain combined with a fully thoracoscopic VBT and limited pleural approach seems a safe and effective alternative to the chest drain. This technique allows to remove the drain on the first postoperative day, thus simplifying the management of the patients and improving their comfort.

Multi-Modal Data Correspondence for the 4D Analysis of the Spine with Adolescent Idiopathic Scoliosis.

Adolescent idiopathic scoliosis is a three-dimensional spinal deformity that evolves during adolescence. Combined with static 3D X-ray acquisitions, novel approaches using motion capture allow for the analysis of the patient dynamics. However, as of today, they cannot provide an internal analysis of the spine in motion. In this study, we investigated the use of personalized kinematic avatars, created with observations of the outer (skin) and internal shape (3D spine) to infer the actual anatomic dynamics of the spine when driven by motion capture markers. Towards that end, we propose an approach to create a subject-specific digital twin from multi-modal data, namely, a surface scan of the back of the patient and a reconstruction of the 3D spine (EOS). We use radio-opaque markers to register the inner and outer observations. With respect to the previous work, our method does not rely on a precise palpation for the placement of the markers. We present the preliminary results on two cases, for which we acquired a second biplanar X-ray in a bending position. Our model can infer the spine motion from mocap markers with an accuracy below 1 cm on each anatomical axis and near 5 degrees in orientations.

Long-term Outcomes of Tibial Spine Avulsion Fractures After Open Reduction With Osteosuturing Versus Arthroscopic Screw Fixation: A Multicenter Comparative Study.

Background: More information is needed regarding return to preinjury sport levels and patient-reported outcomes after tibial spine avulsion (TSA) fracture, which is most common in children aged 8 to 12 years. Purpose: To analyze return to play/sport (RTP), subjective knee-specific recovery, and quality of life in patients after TSA fracture treated with open reduction with osteosuturing versus arthroscopic reduction with internal screw fixation. Study Design: Cohort study; Level of evidence, 3. Methods: This study included 61 patients <16 years old with TSA fracture treated via open reduction with osteosuturing (n = 32) or arthroscopic reduction with screw fixation (n = 29) at 4 institutions between 2000 and 2018; all patients had at least 24 months of follow-up (mean ± SD, 87.0 ± 47.1 months; range, 24-189 months). The patients completed questionnaires regarding ability to return to preinjury-level sports, subjective knee-specific recovery, and health-related quality of life, and results were compared between treatment groups. Univariate and multivariate logistic regression analyses were conducted to determine variables associated with failure to return to preinjury level of sport. Results: The mean patient age was 11 years, with a slight male predominance (57%). Open reduction with osteosuturing was associated with a quicker RTP time than arthroscopy with screw implantation (median, 8.0 vs 21.0 weeks; P < .001). Open reduction with osteosuturing was also associated with a lower risk of failure to RTP at preinjury level (adjusted odds ratio, 6.4; 95% CI, 1.1-36.0; P = .035). Postoperative displacement >3 mm increased the risk of failure to RTP at preinjury level regardless of treatment group (adjusted odds ratio, 15.2; 95% CI, 1.2-194.9; P = .037). There was no difference in knee-specific recovery or quality of life between the treatment groups. Conclusion: Open surgery with osteosuturing was a more viable option for treating TSA fractures because it resulted in a quicker RTP time and a lower rate of failure to RTP as compared with arthroscopic screw fixation. Precise reduction contributed to improved RTP.

Meniscal Allograft Transplants in Skeletally Immature Patients: A Systematic Review of Indications and Outcomes.

Meniscal lesions in skeletally immature patients can lead to joint degradation and knee instability. Meniscal allograft transplant (MAT) surgery is a solution to maintain knee stability. There is a lack of consensus on MAT surgery outcomes in pediatric patients. A systematic review was conducted according to the PRISMA guidelines. PubMed, Scopus and EMBASE databases were searched from 1965 to June 2022. Studies were evaluated using the Newcastle-Ottawa Scale (NOS). Three studies were selected, and 58 patients were included (mean age 15.9 years) in total. The lateral meniscus was involved in 82.8% of all MAT surgeries. Post-meniscectomy syndrome and discoid meniscus were the main indications for MAT surgery. All studies reported improved subjective clinical scores and levels of sport after the surgery. The complication rate was 27.5%. Partial meniscectomy, meniscus knot removal, chondral defect treatment and lysis of adhesions were the most frequent procedures performed during reoperation. MAT surgery can improve clinical outcomes in pediatric patients with strictly selected indications. MAT surgery is safe when there are no limb asymmetries or malalignments, but it remains a challenging procedure with a high complication rate. Long-term follow-up is needed for definitive statements on the use of MAT in skeletally immature patients.

Vertebral Body Tethering in AIS Management-A Preliminary Report.

Vertebral Body Tethering (VBT) is a recently developed surgical technique for the treatment of progressive and severe scoliosis in patients with significant growth potential. It has been used since the first exploratory series, which showed encouraging results on the progressive correction of the major curves. This study reports on a retrospective series of 85 patients extracted from a French cohort, with a follow-up at a minimum of two years after a VBT with recent screws-and-tether constructs. The major and compensatory curves were measured pre-operatively, at the 1st standing X-ray, at 1 year, and at the last available follow-up. The complications were also analyzed. A significant improvement was observed in the curve magnitude after surgery. Thanks to growth modulation, both the main and the secondary curves continued to progress over time. Both the thoracic kyphosis and lumbar lordosis remained stable over time. Overcorrection occurred in 11% of the cases. Tether breakage was observed in 2% of the cases and pulmonary complications in 3% of the cases. VBT is an effective technique for the management of adolescent idiopathic scoliosis patients with residual growth potential. VBT opens an era of a more subtle and patient-specific surgical management of AIS that considers parameters such as flexibility and growth.

Safety and Efficacy of Stand-Alone Bioactive Glass Injectable Putty or Granules in Posterior Vertebral Fusion for Adolescent Idiopathic and Non-Idiopathic Scoliosis.

Posterior spinal fusion (PSF) is the standard procedure for the treatment of severe scoliosis. PSF is a standard procedure that combines posterior instrumentation with bone grafting and/or bone substitutes to enhance fusion. The aim of this retrospective study was to evaluate and compare the post-operative safety and efficiency of stand-alone bioactive glass putty and granules in posterior spine fusion for scoliosis in a paediatric cohort. A total of 43 children and adolescents were included retrospectively. Each patient's last follow-up was performed at 24 months and included clinical and radiological evaluations. Pseudarthrosis was defined as a loss of correction measuring >10° of Cobb angle between the pre-operative and last follow-up measurements. There was no significant loss of correction between the immediate post-operative timepoint and the 24-month follow-up. There was no sign of non-union, implant displacement or rod breakage. Bioactive glass in the form of putty or granules is an easily handled biomaterial but still a newcomer on the market. This study shows that the massive use of bioactive glass in posterior fusion, when combined with proper surgical planning, hardware placement and correction, is effective in providing good clinical and radiological outcomes.

Congenital Cervical Spinal Deformities.

Malformations of the cervical spine are a challenge in pediatric orthopedic surgery since the treatment options are limited. These congenital anomalies are often syndrome-related and have multiple repercussions on the function and statics of the cervical spine in all three planes. They are related to developmental abnormalities during the somite segmentation that occurs during the third week of embryonic development. Successful somitogenesis requires proper functioning of a clock regulated by complex signaling pathways that guide the steps needed to form the future spine. There is no specific classification for vertebral malformations at the cervical level. To characterize the progressive nature of a malformation, one must use general classifications. In the specific case of Klippel-Feil syndrome, these malformations can affect several vertebral levels in a continuous or discontinuous manner, but also the vertebral body and vertebral arch in a variable way. Thus, establishing a reliable prognosis in the coronal and sagittal planes is a complex undertaking. While technical mastery of certain osteotomy procedures has led to advances in the surgical treatment of rigid deformities of the cervical spine, the indications are still very rare. Nevertheless, the procedure has become safer and more accurate because of technical aids such as surgical navigation, robotics and 3D printed models or patient-specific guides. Occipitocervical transitional anomalies have embryological specificities that can explain the bony malformations seen at this level. However, most are rare, and the main concern is identifying any instability that justifies surgical stabilization. The presence of a cervical spine anomaly should trigger the search for occipitocervical instability and vice-versa.

Thoracoscopic Anterior Vertebral Body Tethering in Lenke Type-1 Right Adolescent Idiopathic Scoliosis.

Background: Vertebral body tethering (VBT) is indicated for skeletally immature patients with progressive adolescent idiopathic scoliosis (AIS) who have failed or are intolerant of bracing and who have a major coronal curve of 40° to 65°. The vertebral body must be structurally and dimensionally adequate to accommodate screw fixation, as determined radiographically. The best indication for VBT is a flexible single major thoracic curve with nonstructural compensating lumbar and proximal thoracic curves (Lenke 1A or 1B). VBT allows for progressive correction of the deformity without spinal fusion by utilizing a minimally invasive fluoroscopic technique. Description: The procedure for a right thoracic curve is performed with use of a right thoracoscopic approach with the patient in the left lateral decubitus position. The thoracoscope is introduced through a portal at the apex of the curvature in the posterior axillary line. Instrument portals are created lateral to each vertebral body in the mid-axillary line. Screws are inserted into each vertebral body under biplanar fluoroscopic control and with intraoperative neuromonitoring. An electroconductivity probing device, while not mandatory, is routinely utilized at our practice. The tether is attached to the most proximal screw of the construct, and then reduction is obtained sequentially by tensioning the tether from one vertebral screw to the next. Alternatives: Bracing is the gold-standard treatment for progressive AIS involving the immature spine. The most commonly utilized surgical treatment is posterior spinal fusion (PSF), which should be considered when the major coronal curve exceeds 45°. Rationale: PSF has proven to be a dependable technique to correct scoliotic deformities. It has a low complication rate and good long-term outcomes. However, concerns exist regarding the stiffness conferred by PSF and the long-term effects of adjacent segment disease. Thus, interest had developed in non-fusion solutions for AIS correction. VBT utilizes the Hueter-Volkmann principle to guide growth and correct deformity. Compressive forces applied to the convexity of the deformity by a polyethylene tether allow the patient's growth to realign the spine. Intraoperative correction triggers growth modulation, and most of the modulation seems to occur during the first 12 months postoperatively. The best results have been seen with a short Lenke type-1A curve in a patient with closed triradiate cartilage, a Risser 3 or lower (ideally Risser 0) iliac apophysis, and a flexible curve characterized by a 50% reduction of the major coronal curve angle on side-bending radiographs. Expected Outcomes: In 57 immature patients with a Lenke type-1A or 1B curve (i.e., a 30° to 65° preoperative Cobb angle), Samdani et al.3 found a main thoracic Cobb angle reduction from 40° ± 7° preoperatively to 19° ± 13° at 2 years after VBT. In the sagittal plane, the T5-T12 kyphosis measured 15° ± 10° preoperatively, 17° ± 10° postoperatively, and 20° ± 13° at 2 years. No major neurologic or pulmonary complications occurred. A total of 7 (12.3%) of the 57 patients underwent surgical revision, including 5 for overcorrection and 2 to span additional vertebrae. In a study of 21 skeletally mature patients, Pehlivanoglu et al.4 found that the Cobb angle was reduced from 48° preoperatively to 16° on the first-erect postoperative radiograph and finally to 10° at the latest follow-up (mean, 27.4 months). The 2 main complications of VBT reported in the literature are overcorrection and tether breakage. Both may require revision, which explains the higher rate of revision observed for VBT compared with PSF. Important Tips: Good patient selection is important. VBT is most appropriate in cases of a flexible Lenke type-1A or 1B curve in an immature child before Risser stage 3 and after triradiate cartilage closure.Always monitor and control screw positioning in both anteroposterior and lateral planes fluoroscopically.The screws should be placed parallel to the vertebral end plates or, even better, be angled inferiorly for the upper vertebrae and angled superiorly for the lower vertebrae to decrease the risk of pull-out when tensioning the device and during growth modulation. Less tension on the uppermost and lowermost instrumented vertebrae than at the apex, as controlled by the tensioning device, can also help to limit pull-out. Acronyms and Abbreviations: VBT = vertebral body tetheringAIS = adolescent idiopathic scoliosisIONM = intraoperative neuromonitoringPSF = posterior spinal fusionUIV = upper instrumented vertebraLIV = lower instrumented vertebraAP = anteroposteriorK-wire = Kirschner wire.

Virtual Scoliosis Surgery Using a 3D-Printed Model Based on Biplanar Radiographs.

The aim of this paper is to describe a protocol that simulates the spinal surgery undergone by adolescents with idiopathic scoliosis (AIS) by using a 3D-printed spine model. Patients with AIS underwent pre- and postoperative bi-planar low-dose X-rays from which a numerical 3D model of their spine was generated. The preoperative numerical spine model was subsequently 3D printed to virtually reproduce the spine surgery. Special consideration was given to the printing materials for the 3D-printed elements in order to reflect the radiopaque and mechanical properties of typical bones most accurately. Two patients with AIS were recruited and operated. During the virtual surgery, both pre- and postoperative images of the 3D-printed spine model were acquired. The proposed 3D-printing workflow used to create a realistic 3D-printed spine suitable for virtual surgery appears to be feasible and reliable. This method could be used for virtual-reality scoliosis surgery training incorporating 3D-printed models, and to test surgical instruments and implants.

Development and Operation of an Experimental System to Measure the Moments Generated in the Finger Joints.

Little information is available on the forces that fingers can generate, and few devices exist to measure the forces they can create. The objective of this paper is to propose an experimental device to measure the moments generated by finger joints. The idea is to focus on a single joint and not on the effort generated by the whole finger. A system leaving only one joint free is developed to measure the maximum attainable moment in different joint positions between the extended and flexed finger. The device is tested on the proximal interphalangeal joints of the index fingers of thirty people for both hands. The results show a dispersion of results from one person to another but with similar trends in the evolution of the maximum achievable moment depending on the angle. Average values of the maximum moments attained by men and women for both hands are given for all angular positions of the joint. The results are analysed using principal component analysis. This analysis shows that four main modes represent more than 99% of the signal and allow the reconstruction of all the data for all the subjects. The four modes obtained can be used as a basis for the development of finger devices by hospital practitioners.

Comparison of Trunk Motion between Moderate AIS and Healthy Children.

Analysis of kinematic and postural data of adolescent idiopathic scoliosis (AIS) patients seems relevant for a better understanding of biomechanical aspects involved in AIS and its etiopathogenesis. The present project aimed at investigating kinematic differences and asymmetries in early AIS in a static task and in uniplanar trunk movements (rotations, lateral bending, and forward bending). Trunk kinematics and posture were assessed using a 3D motion analysis system and a force plate. A total of fifteen healthy girls, fifteen AIS girls with a left lumbar main curve, and seventeen AIS girls with a right thoracic main curve were compared. Statistical analyses were performed to investigate presumed differences between the three groups. This study showed kinematic and postural differences between mild AIS patients and controls such as static imbalance, a reduced range of motion in the frontal plane, and a different kinematic strategy in lateral bending. These differences mainly occurred in the same direction, whatever the type of scoliosis, and suggested that AIS patients behave similarly from a dynamic point of view.

The effects of vertebral body tethering on sagittal parameters: evaluations from a 2-years follow-up.

INTRODUCTION: While the effects of VBT on coronal parameters have been investigated in various studies, this has not yet been the case for sagittal parameters. This is of particular relevance considering that VBT does not allow direct correction of the sagittal profile. Thus, we investigated the effects of VBT on sagittal parameters in patients with adolescent idiopathic scoliosis. MATERIALS AND METHODS: Retrospective, 2-Center study. Patients who underwent VBT and presented a 2-years follow-up were included. The differences in sagittal parameters were evaluated, along with modifications of sagittal profile following Abelin-Genevois' classification. RESULTS: Data from 86 patients were obtained. Mean Cobb angle was 52.4 ± 13.9° at thoracic level and 47.6 ± 14.3° at lumbar level before surgery, and 28.5 ± 13.6 and 26.6 ± 12.7° at the 2-year follow-up, respectively. Mean thoracic kyphosis increased from 28.3 ± 13.8 to 33 ± 13°, the lumbar lordosis (LL) was unvaried (from 47.5 ± 13.1 to 48.4 ± 13.5°), PT decreased from 9.4 ± 8.5 to 7.4 ± 6.1°, the sagittal vertical axis SVA decreased from 4.5 ± 31.4 to - 3.6 ± 27.9 mm. No kyphotic effect on LL in patients who underwent lumbar instrumentation was observed. Before surgery, 39 patients had a type 1 sagittal profile, 18 were type 2a, 14 type 2b and 15 type 3. Postoperatively, 54 were type 1, 8 were 2a, 13 were 2b and 11 were type 3. CONCLUSIONS: VBT positively influences sagittal parameters and does not have a kyphotic effect on LL.

Assessing gastric contents in children before general anesthesia for acute extremity fracture: An ultrasound observational cohort study.

STUDY OBJECTIVE: Children with acute extremity fractures are commonly considered to be at risk of pulmonary aspiration of gastric contents during the induction of anesthesia. This study aimed to evaluate the proportion of such children with high-risk gastric contents using preoperative gastric ultrasound. DESIGN: Prospective observational cohort study. SETTING: Specialist pediatric center over a 30-month period. PATIENTS: Children undergoing surgery within 24 h of an acute extremity fracture. INTERVENTIONS: None. MEASUREMENTS: According to preoperative qualitative and quantitative ultrasound analysis of the antrum in the supine and right lateral decubitus positions, gastric contents were classified as high-risk (clear liquid with calculated gastric fluid volume > 0.8 mL.kg-1, thick liquid, or solid) or low-risk. Factors associated with high-risk gastric contents were identified by multivariable analysis. MAIN RESULTS: Forty-one children (37%; 95% CI: 28-47) of the 110 studied (mean(SD) age: 10(3) years) presented with high-risk gastric contents, including 26 (24%; 95% CI: 16-33) with solids/thick liquid contents. Scanning in the supine position alone allowed a diagnosis of high-risk gastric contents in 23 children out of the 63 for whom right lateral decubitus positioning was unfeasible. Gastric contents remained undetermined in 41 children, including one with a non-contributory gastric US (antrum non-visualized). Proximal limb fractures (OR: 2.5; 95% CI: 1.0-6.2), preoperative administration of opioids (OR: 3.9; 95% CI: 1.1-13), and the absence of bowel sounds (OR: 8.0; 95% CI: 1.4-44) were associated with high-risk gastric contents. Performing surgery the day following the trauma was a protective factor (OR: 0.1; 95% CI: 0.0-0.6). No cases of pulmonary aspiration occurred. CONCLUSIONS: At least one-third of children with an acute isolated extremity fracture had preoperative gastric contents identified as high risk for pulmonary aspiration. Although preoperative history can guide anesthetic strategy in this population, ultrasound allowed clear stratification of the risk of aspiration in most cases.

An arthroscopic repair technique for proximal anterior cruciate tears in children to restore active function and avoid growth disturbances.

PURPOSE: The aim of this study was to assess midterm clinical outcomes in Tanner 1-2 patients with proximal anterior cruciate ligament (ACL) tears following arthroscopic-surgical repair using an absorbable or an all-suture anchor. METHODS: Fourteen (9.2 ± 2.9 years-old) of 19 skeletally immature patients reached the 2 years of clinical follow-up. Physical examinations included the Lachman test, Pivot-shift test, One-leg Hop test, Pedi-IKDC as well as Lysholm and Tegner activity scores; knee stability was measured with a KT-1000 arthrometer. Overall re-rupture rates were also evaluated in all operated patients. RESULTS: At 2 years post-surgery, the Lysholm score was 93.6 ± 4.3 points, and the Pedi-IKDC score was 95.7 ± 0.1. All patients returned to the same sport activity level as prior to ACL lesion within 8.5 ± 2.9 months, with one exception who reported a one-point reduction in their Tegner Activity score. No leg-length discrepancies or malalignments were observed. Four patients presented grade 1 Lachman scores, and of these, three presented grade 1 (glide) score at Pivot-shift; clinical stability tests were negative for all other patients. Anterior tibial shift showed a mean side-to-side difference of 2.2 mm (range 1-3 mm). The One-leg Hop test showed lower limb symmetry (99.9% ± 9.5) with the contralateral side. Overall, 4 out of 19 patients presented a re-rupture of the ACL with a median time between surgery and re-rupture of 3.9 years (range 1-7). CONCLUSION: This surgical technique efficiently repairs proximal ACL tears, leading to a restoration of knee stability and a quick return to an active lifestyle, avoiding growth plate disruption. LEVEL OF EVIDENCE: IV.

Clinical presentation and surgical treatment of distal fibular non-union with talus chondral lesions in a pediatric patient: a case report.

BACKGROUND: In children, fracture non-union is uncommon yet, curiously, non-union of distal fibula fractures are rarely reported. Historically, the most common treatment of a lateral malleolus fracture after an ankle sprain is conservative, which usually leads to fracture union. However, even in clinically stable ankles, subsequent pain arising from fracture site could suggest non-union, thereby necessitating reexamination and possible secondary treatment. CASE PRESENTATION: We report the case of an 8-year-old girl with an epiphyseal distal fibula fracture complicated with a symptomatic non-union associated with the chondral flap of the talar dome after conservative treatment. Surgical excision of the fragment and chondroplasty was performed and resulted in an excellent clinical outcome. CONCLUSION: This case report illustrates the necessity of particularly meticulous evaluation of pediatric post-traumatic ankle pain. Surgical treatment as well as talar chondral evaluation should be taken into consideration in the treatment of pediatric distal fibular nonunion.

Pediatric navicular dorsal osteochondroma: a rare case of navicular-cuneiform impingement.

Osteochondroma is one of the most common benign bone tumors; however, as it rarely affects any bones in feet, it may easily escape detection without rigorous examination. We present an exceptionally rare case of tarsal navicular dorsal osteochondroma diagnosed in an 11-year-old female child affected by chronic foot pain. Radiographs, MRI, and computed tomography scan revealed bony excrescences extending outward from the navicular bone. After conservative treatment failed, the navicular dorsal exostosis was excised in open surgery with complete resolution of symptoms. Navicular-cuneiform impingement was diagnosed by instrumental and intraoperative techniques. Histological analysis confirmed the diagnosis of navicular dorsal osteochondroma. This case report illustrates the necessity of particularly rigorous evaluation of the substrates of pediatric chronic foot pain.

Prediction of brace effect in scoliotic patients: blinded evaluation of a novel brace simulator-an observational cross-sectional study.

PURPOSE: Bracing is the most commonly used treatment for scoliosis. But braces remain predominantly "handcrafted." Our objective was to create a novel brace simulator using a high-fidelity 3D "avatar" of the patient's trunk. METHODS: An observational cross-sectional study was constructed. The inclusion criteria were patients with a moderate idiopathic scoliosis (between 15° and 35° of Cobb angle) aged between 9 and 15 years old with an indication of brace treatment. Twenty-nine scoliotic patients, 25 girls and four boys, with a mean age of 12.4 years were included. Twenty right thoracic and 14 left lumbar were measured with a mean Cobb angle of 24°. 3D "avatars" were generated using a novel technology called the "anatomy transfer." Biomedical simulations were conducted by engineers who were blinded to the clinical effect of the real patient brace. The in-brace Cobb angle effect (real effect) was compared with the virtual numeric in-brace Cobb angle observed using the blindly constructed avatar (simulation effect). RESULTS: Real and simulated in-brace Cobb angle were compared using a paired two-sided Student's t test. The real mean Cobb angle was 11° and 17° in the simulation which was statistically significant. The strength of prediction of the simulation was assessed for each individual patient; 76% of the real in-brace Cobb angles had good and moderate prediction (± 10°). CONCLUSIONS: Incorporating high-fidelity copy of the entire 3D shape of the patient's trunk and multiple 3D-reconstructed bony images into an anatomical reference avatar resulted in moderate-to-good prediction of brace effect in three quarters of patients. These slides can be retrieved under Electronic Supplementary Material.

Congenital lumbar kyphosis with skin ulceration and osteomyelitis in a myelomeningocele child: a case report.

INTRODUCTION: Kyphosis is a frequent problem in children with spina bifida, and this deformity may cause different complications as respiratory insufficiency, bowel dysfunction, and skin ulcers. CASE REPORT: We report on a 13-year-old myelomeningocele male with a lumbar kyphoscoliosis associated to a septic skin ulceration that resulted in an acute sepsis. An X-ray revealed a kyphosis of 110° and a scoliosis of 25° between T9 and L5. The wound and blood cultures showed Staphylococcus aureus colonization, and an appropriate antibiotic therapy was started. An MRI showed a wedged vertebra at T12, a laminae defects from T8 to the sacrum, and a spondylitis at T12-L1. Ulcer resection and kyphectomy from T12 to L3 were performed "en bloc," and the spine was instrumented fromT7 to S1. After the surgery, the kyphosis was corrected to 10°, and the scoliosis was corrected to 0°. At an 18-month follow-up, a solid bony fusion was obtained, and no recurrence of skin ulcer was reported. CONCLUSION: Antibiotherapy associated to one-step "en-bloc" surgical debridement and kyphectomy should be considered as a valid option to eradicate the infection and to correct the spine deformity in kyphosis due to myelomeningocele associated to septic skin ulcer and spondylitis.

Computer assisted surgery in preoperative planning of acetabular fracture surgery: state of the art.

INTRODUCTION: The development of imaging modalities and computer technology provides a new approach in acetabular surgery. AREAS COVERED: This review describes the role of computer-assisted surgery (CAS) in understanding of the fracture patterns, in the virtual preoperative planning of the surgery and in the use of custom-made plates in acetabular fractures with or without 3D printing technologies. A Pubmed internet research of the English literature of the last 20 years was carried out about studies concerning computer-assisted surgery in acetabular fractures. The several steps for CAS in acetabular fracture surgery are presented and commented by the main author regarding to his personal experience. EXPERT COMMENTARY: Computer-assisted surgery in acetabular fractures is still initial experiences with promising results. Patient-specific biomechanical models considering soft tissues should be developed to allow a more realistic planning.