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

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

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

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

A new technique for proximal femoral resection in non-ambulatory patients with cerebral palsy.

Proximal femoral resection may be proposed to non-ambulatory patients with cerebral palsy and chronic painful hip dislocation. McCarthy's technique confers good results but does not solve the problems related to femoral reascension (bone migration causing painful osseous or cutaneous conflict). We describe a new technique of resection-interposition of the proximal end of the femur which preserves the greater trochanter by an orthogonal osteotomy below the lesser trochanter while maintaining the gluteal-vastus lateralis strut in continuity. A suture of the remaining joint capsule upon itself and a trans-trochanteric capsulodesis are associated to stabilize the cephalic displacement of the femur.

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

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

Skeletal Ryanodine Receptors Are Involved in Impaired Myogenic Differentiation in Duchenne Muscular Dystrophy Patients.

Duchenne muscular dystrophy (DMD) is characterized by progressive muscle wasting following repeated muscle damage and inadequate regeneration. Impaired myogenesis and differentiation play a major role in DMD as well as intracellular calcium (Ca2+) mishandling. Ca2+ release from the sarcoplasmic reticulum is mostly mediated by the type 1 ryanodine receptor (RYR1) that is required for skeletal muscle differentiation in animals. The study objective was to determine whether altered RYR1-mediated Ca2+ release contributes to myogenic differentiation impairment in DMD patients. The comparison of primary cultured myoblasts from six boys with DMD and five healthy controls highlighted delayed myoblast differentiation in DMD. Silencing RYR1 expression using specific si-RNA in a healthy control induced a similar delayed differentiation. In DMD myotubes, resting intracellular Ca2+ concentration was increased, but RYR1-mediated Ca2+ release was not changed compared with control myotubes. Incubation with the RYR-calstabin interaction stabilizer S107 decreased resting Ca2+ concentration in DMD myotubes to control values and improved calstabin1 binding to the RYR1 complex. S107 also improved myogenic differentiation in DMD. Furthermore, intracellular Ca2+ concentration was correlated with endomysial fibrosis, which is the only myopathologic parameter associated with poor motor outcome in patients with DMD. This suggested a potential relationship between RYR1 dysfunction and motor impairment. Our study highlights RYR1-mediated Ca2+ leakage in human DMD myotubes and its key role in myogenic differentiation impairment. RYR1 stabilization may be an interesting adjunctive therapeutic strategy in DMD.

Dysplasia Epiphysealis Hemimelica Presenting as Multiple Loose Bodies: A Case Report.

CASE: A 11-year-old boy with no medical history presented with a protective limp and worsening mechanical pain in his left knee. No recent traumatic or infectious history was reported. Radiographs and ultrasonography showed multiple intra-articular loose bodies with osteocartilaginous signal. Dysplasia epiphysealis hemimelica (DEH) was confirmed by magnetic resonance imaging (MRI) and computed tomography (CT) scan. This is the first report that describes the presence of loose bodies in a knee without previous surgery as a possible case of DEH. CONCLUSION: We emphasize the use of CT scan and MRI before any surgical procedure when intra-articular loose bodies are unexpectedly discovered.

Change in shoulder external rotation strength and motion after lower trapezius transfer to the infraspinatus in children with obstetric brachial plexus palsy.

PURPOSE: Quantifying changes in shoulder external rotation range of motion and strength after lower trapezius transfer in children with obstetric brachial plexus palsy (OBPP). METHODS: This prospective study included five children with sequelae of OBPP, with a mean age of 6.4 years (range: 4-12 years) who underwent lower trapezius tendon transfer to restore active external rotation (ER) of the shoulder. Pre-operatively and at a 12-month follow-up assessment, we analyzed the passive and active shoulder ER, the modified Mallet score, and the shoulder rotator muscles strength using an isokinetic device. RESULTS: Clinical parameters improved significantly after trapezius transfer pre-operative passive ER from -8° (range: -20-0°) to 37° (range: 15-50°) (p = 0.035), the modified Mallet score from 13 (range: 10-15) to 18 (range: 17-19) (p = 0.035). Strength testing revealed improved ER muscle strength in all five cases; the mean Peak Torque increased from 1.95 to 4.46 N·m, albeit non-significantly (p = 0.062). Two patients exhibited a winged scapula post-operatively. CONCLUSION: Lower trapezius transfer seems encouraging to restore shoulder external rotation in OBPP children but with non-significant strength improvement. TRIAL REGISTRATION: 18/07/31/5783, December 22, 2018.

Acetabular retroversion after triple pelvic osteotomy for Legg-Calvé-Perthes disease and its impact on the femoroacetabular impingement: a case/control study at 15 years of follow-up.

The objective of this study was to compare the effect of triple pelvic osteotomy (TPO) in Legg-Calvé-Perthes disease (LCPD) on acetabular version in a group of patients who developed a femoroacetabular impingement (FAI) and a control group without FAI. Patients who received a TPO for unilateral LCPD were retrospectively included. Patients with bilateral LCPDs, requiring TPO with femoral procedures, or with incomplete imaging were excluded. Seven patients with FAI (FAI+) and eight patients without FAI (FAI-) were evaluated at a mean follow-up of 14.8 years. The two groups were comparable in demographic data, age at diagnosis, Herring score, and BMI. We measured anatomical acetabular version on computed tomography scans, the difference (delta) of acetabular version between the operated hip and the healthy hip, the McKibbin (femoral version + acetabular version), Stulberg, and Tönnis scoring system. The two groups were not statistically different on the Stulberg and Tönnis scores. All operated hip acetabula were retroverted, FAI+: -8.41° (range, -44 to 10.5), FAI-: -3.38° (range, -37.3 to 11.5) (P = 0.61). The average delta was FAI+: 23.79° (range, 1.5-59.5), FAI-: 20.14° (range, 5-45.3) (P = 0.68). All seven patients of the FAI+ group have pathologic McKibbin index (<30°) versus only four of the FAI- group (P = 0.03). TPO induces acetabular retroversion in patients with LCPD. This retroversion, assessed in a static benchmark (anterior pelvic plane), does not in itself explain the FAI.

Esophageal perforation caused by a thoracic pedicle screw.

This grand round raises the risk of a rare complication that can be avoided with the knowledge of the particular anatomy of scoliosis vertebra. Transpedicular screws have been reported to enhance the operative correction in scoliosis surgery. The narrow and inconsistent shape of the thoracic pedicles makes the placement of pedicle screws technically challenging. Furthermore, in thoracic curves, the close proximity of the spinal cord and major soft tissue structures also adds a greater risk to the procedure. The esophagus lies close to the upper thoracic vertebras and, an anterior cortical perforation can cause esophageal injury. We report a case of anterior cortical perforation by a T4 pedicle screw complicated by an esophageal perforation in a 15-year-old girl with convulsive encephalopathy. She was operated for a severe neurological scoliosis (Rett syndrome). Her neurological condition deteriorated 3 years after the posterior spinal surgery, requiring a percutaneous gastrostomy. An intra-esophageal screw was discovered incidentally during an endoscopy. We decided not to remove this screw, because the patient's health status presented a surgical contraindication. The patient showed no apparent discomfort at the 10-year follow-up examination after spinal arthrodesis. Esophageal perforation caused by a posterior pedicle screw is very rare. We highlight the risk of injury to esophagus from pedicle screws in upper thoracic vertebra. The systematic removal of a malpositioned screw must be discussed, on a case-to-case benefit-risk basis, especially if the patient has numerous comorbidities, given the long-term tolerance of a number of these improperly positioned implants.

Intra-medullary osteosclerosis of the tibia in children.

BACKGROUND: Intra-medullary osteosclerosis of the tibia is a rare condition characterised by chronic pain due to diaphyseal hyperostosis with no detectable triggering factor. The main differential diagnoses are stress fracture and osteoid osteoma. Of the few cases reported to date, most were in adults. The objective of this study was to assess paediatric patients with intra-medullary osteosclerosis to determine whether the first visit provides sufficient information to establish the diagnosis and rule out both osteoid osteoma and stress fracture, whether a biopsy is required, and which treatment is optimal. HYPOTHESIS: The diagnosis of intra-medullary osteosclerosis of the tibia can be made at the first visit. PATIENTS AND METHODS: Seven paediatric patients, 4 males and 3 females, with a mean age of 11 years, were included in this retrospective study. We evaluated the clinical features, findings from imaging studies (standard radiographs, computed tomography, magnetic resonance imaging, and bone scintigraphy), and treatment outcomes. RESULTS: At the first visit, all patients had a painful swelling at the middle of the shin and imaging study evidence of antero-lateral tibial cortical thickening extending into the medullary cavity; in 5 patients, a linear lucency was visible. No other bone abnormalities were seen. Treatments included non-operative measures, pinning, and nailing. None of these treatments provided permanent bone healing or pain relief, although transitory freedom from pain with or without radiological bone healing was achieved. DISCUSSION: Intra-medullary osteosclerosis of the tibia is rarely reported and therefore probably underdiagnosed. Distinctive characteristics of the cortical and endosteal thickening include location at the antero-lateral mid-diaphysis and, in some cases, the concomitant presence of a linear lucency that can provide the early diagnosis. The distinctive radiological features allow differentiation from a stress fracture. The management is challenging. LEVEL OF EVIDENCE: IV, retrospective observational study.

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

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

Computerized static posturography and laterality in children. Influence of age.

PURPOSE: The present study aims to explore relationships between footedness and posturographic assessment in children aged from 4 to 10. A real-time computerised device was used on a force plate for movement analysis. It requires a static posturography to assess postural control of children with the same handedness and footedness. METHODS: Thirty eight right-handed and right-footed children organized in three age groups of 4 to 6 years old, 6 to 8 years old and 8 to 10 years old participated in the study. Two statical tests, the Unilateral Stance (US) and the Weight Bearing Squat (WBS) were performed, jointly with a dynamic balance examination (Limits of Stability (LOS)). All these tests were executed to explore the body capability of the right/left side. RESULTS: The study demonstrated significant differences involving the right/left side among the three age groups. Better performance on the youngest children's right part and on the oldest children's left part was observed. Differences between the left and right sides of the body were noticeably revealed by posturographic assessments in right-handed and right-footed children. CONCLUSIONS: Age seemed to be a determinant for these outcomes. Maturation of the vestibular at the ages of 6 or 7 years might explain the observed differences between the youngest children and olderchildren.

Autologous osteochondral mosaicplasty in osteochondritis dissecans of the patella in adolescents.

PURPOSE: Osteochondritis dissecans of the patella (OCDP) is rare in adolescents. The objective of this study was to evaluate functional results of OCDP management in adolescents with mosaicplasty and to analyze proper integration of osteochondral grafts via MRI. METHODS: This is a retrospective series of eight cases of OCDP treated by mosaicplasty. Mean age at the surgery was 15 years (range 12-17). Clinical features were represented by retropatellar pain, hydarthrosis, locking and crepitus. All patients benefited from knee radiographs as well as pre-operative MRI. Six OCDP were evaluated International Cartilage Repair Society (ICRS) grade III and two were ICRS grade IV. Mean surface of the lesion was 97.5 mm2. The pre- and post-operative assessments were conducted with scores obtained on the IKDC subjective knee evaluation form, Lysholm knee score, and Tegner activity scale. These assessments were completed by post-operative MRI. The magnetic resonance observation of cartilage repair tissue (MOCART) score was calculated from the latest MRI examination conducted after surgery. RESULTS: Mean follow-up was 28.6 months. At the latest follow-up, the mean IKDC score was 86.5, Lysholm score was 89, and Tegner activity scale score was 6.2 (pre-operative scores were respectively 49.9, 53.8, and 4.5). Radiographs and MRI showed a complete integration of grafts at the latest follow-up with a satisfactory reconstruction of the joint surface. Mean MOCART score was 75/100. CONCLUSIONS: Autologous osteochondral mosaicplasty to manage OCDP in adolescents appears to be a reliable technique on the short term to restore patellar joint surface and obtain satisfactory functional results.

Long-term Results After Extensive Soft Tissue Release in Very Severe Congenital Clubfeet.

BACKGROUND: The purpose of this study was to determine the long-term results, at an average follow-up of 22 years, in 66 patients (105 clubfeet) with very severe congenital idiopathic clubfeet according to the Dimeglio-Bensahel scale. METHODS: Patients were treated with an extensive soft tissue release in infancy. Results of the treatment were assessed according to the 100-point system of Ghanem-Seringe. At the latest follow-up, all participants were evaluated with regard to pain and the overall function of the lower extremities. At the latest follow-up, anteroposterior and lateral radiographs of the affected foot and the contralateral normal foot, when applicable, were performed. RESULTS: In total, 92% of the patients were satisfied. The mean functional score of Ghanem-Seringe was 70.4 points. No foot had an excellent result, 19 feet had a good result, 16 had a fair result, and 70 had a poor result. A total of 86 feet were painful after strenuous activities or during walking. Eleven patients walked with a limp. In total, 82 feet were stiff. Ankle dorsiflexion and plantar flexion averaged 4.0±4.5 degrees and 19.9±10.7 degrees. Bone deformations such as flattening of the talar dome were observed in 93 feet. Among these feet, the Ghanem score was significantly lower (P<0.05). Necrosis of the navicular was present in 28 feet and subluxation in 82 feet. In total, 32 feet had moderate osteoarthritis. DISCUSSION: Results revealed that despite anatomically and radiologically imperfect clubfeet, most patients demonstrated satisfaction. Satisfaction was not significantly correlated with residual deformity, but with the sensation of a normal gait by the patient and the high initial Dimeglio-Bensahel score. Female patients were significantly less satisfied than male patients because they were more constrained in their social life than boys. Their main dissatisfaction was the atrophy of the calf. We noted several residual deformations. Plantar release seems to contribute to the high rate of overcorrection in our series. Extensive posterolateral and plantar releases in very severe clubfeet was responsible for sequelae, morphologic, anatomic, and functional, especially in adulthood. Deterioration of results over time was confirmed by our series. LEVEL OF EVIDENCE: Level IV.

Small bone islands: unusual clinical symptomatology.

Bone islands are usually considered benign, stable, nonprogressive lesions, radiographically characterized by an ovoid, round, or oblong homogeneously dense and sclerotic focus in the spongiosa, with a preference for the long bones and the pelvis. Benign solitary bone islands are usually believed to be asymptomatic, with no necessity for treatment. Symptomatic bone islands reported in the literature are characterized by a diameter greater than 2 cm, belonging to the category of giant bone islands. The authors report a rare case starting from a painful symptomatology and involving dense sclerotic bone lesions of less than 2 cm, thus falling into the category of small bone islands. The patient underwent a surgical resection to achieve complete recovery. Normally, small bone islands do not explain the pain in patients who present with symptomatology when they are detected during radiographic studies. Based on this case, the authors believe that even small bone islands can be the cause of symptomatology and justify a surgical procedure if all medical investigations suggest no other possible causes of the pain.

Somatic mosaicism in trichorhinophalangeal syndrome: a lesson for genetic counseling.

Trichorhinophalangeal syndrome type I (TRPSI) is a genetic disorder characterized by sparse hair, a bulbous nasal tip, short stature with severe generalized shortening of all phalanges, metacarpal and metatarsal bones and cone-shaped epiphyses. This syndrome is caused by autosomal dominant mutations in the TRPS1 gene. However, because recurrence has been observed in siblings from healthy parents, an autosomal recessive mode of inheritance has also been suggested. We report on a male patient, born to healthy unrelated parents, with TRPSI. Using Sanger sequencing, we identified a mutation in the TRPS1 gene (c.2735 G>A, P.Cys912Tyr). The same mutation was detected as a 10% mosaic mutation by Pyrosequencing in blood-derived DNA from his healthy mother. To our knowledge, this is the first time that somatic mosaicism has been identified in TRPSI. This data combined with the observations of recurrences in siblings from healthy parents modifies the genetic counseling for TRPSI, which should discuss a 5-10 percent recurrence risk for healthy parents with an affected child because of the possibility of germinal mosaicism.

Diurnal changes in postural control in normal children: Computerized static and dynamic assessments.

Mild traumatic brain injury (mTBI) causes postural control deficits and accordingly comparison of aberrant postural control against normal postural control may help diagnose mTBI. However, in the current literature, little is known regarding the normal pattern of postural control in young children. This study was therefore conducted as an effort to fill this knowledge gap. Eight normal school-aged children participated. Posture assessment was conducted before (7-8 a.m. in the morning) and after (4-7 p.m. in the afternoon) school on regular school days using the Balance Master® evaluation system composed of 3 static tests and 2 dynamic balance tests. A significant difference in the weight-bearing squats was detected between morning hours and afternoon hours (P < 0.05). By end of afternoon, the body weight was borne mainly on the left side with the knee fully extended and at various degrees of knee flexion. A significantly better directional control of the lateral rhythmic weight shifts was observed at the end of the afternoon than at morning hours (P < 0.05). In summary, most of our findings are inconsistent with results from previous studies in adults, suggesting age-related differences in posture control in humans. On a regular school day, the capacity of postural control and laterality or medio-lateral balance in children varies between morning and afternoon hours. We suggest that posturographic assessment in children, either in normal (e.g., physical education and sports training) or in abnormal conditions (e.g., mTBI-associated balance disorders), be better performed late in the afternoon.