Adolescent spinal pain: The pediatric orthopedist's point of view.

INTRODUCTION: Ten to twenty percent of persons experience spinal pain during growth. Causes are diverse in adolescents, and it is essential to determine etiology rapidly so as to guide optimal management. HYPOTHESIS: It is important for the pediatric orthopedist to understand the natural history of conditions inducing spinal pain. MATERIAL AND METHODS: A retrospective study included 116 adolescents presenting with spinal pain at the Hôpital Nord (Marseille, France) between January 1, 2009 and January 1, 2014. Malignant tumoral etiologies were excluded. Mean patient age was 13.6 years. Risser ranged between >0 and <5. Interview and clinical examination (skin, spine, neurologic examination, general clinical examination) were systematic; depending on results, complementary examinations (imaging, biology, biopsy) were prescribed. RESULTS: There were 32 cases of non-specific adolescent low back pain, 31 of lumbar or thoracolumbar scoliosis, 23 of spinal growth dystrophy (Scheuermann's disease), 13 of isthmic lysis, 5 of spondylolisthesis, 8 of transitional lumbosacral hinge abnormality, 2 of discal hernia, 1 of osteoid osteoma and 1 of eosinophil granuloma. Treatment was often non-operative when diagnosis was sufficiently early. In case of failure, surgery could generally be considered. DISCUSSION: Correctly indicated non-operative management or surgery changes the natural history of these pathologies. The aim of treatment is to resolve pain in adolescence, as it risks becoming chronic and disabling by adulthood.

Innovative methods to assess upper limb strength and function in non-ambulant Duchenne patients.

Upper limb assessment in non-ambulant patients remains a challenge. We have designed new tools to precisely assess pinch (MyoPinch), grip (MyoGrip), wrist flexion and extension (MyoWrist) strength. We have also designed a new tool to assess the ability of patients to produce repetitive flexion/extension movements of wrist and fingers (MoviPlate). We have assessed the feasibility and reliability of these new tools in 30 non-ambulant patients with Duchenne muscular dystrophy and in 30 age-matched male controls. Existing measures, such as Motor Function Measure, Tapping, and the Brooke Upper Extremity Functional Rating Scale were also performed. Results demonstrated that assessments were feasible in nearly all upper limbs tested for MyoGrip, MyoPinch and MoviPlate. The reliability of all tests, including MyoWrist which was not feasible in the patients presenting with contractures, was excellent in patients as in controls. Motor capacities decrease with the number of months spent in the wheelchair. The scores in the tests were partially correlated with each other, and with clinical measures such as vital capacity, Motor Function Measure, functional hand scale and Brooke score. This study validates a panel of upper limb muscle strength and function measures for Duchenne Muscular Dystrophy which can be applied from controls to extremely weak patients.

[Congenital club foot: treatment in childhood, outcome and problems in adulthood]. / Le pied bot varus equin: traitement chez l'enfant et devenir a l'age adulte.

PURPOSE OF THE SYMPOSIUM: Treatment of idiopathic talipes varus, or congenital clubfoot, is designed to re-align the foot to alleviate pain and allow plantigrade weight bearing with adequate joint motion despite the subnormal radiographic presentation. This symposium was held to review current management practices for congenital clubfoot in children and to analyze outcome in adults in order to propose the most appropriate therapeutic solutions. MANAGEMENT OF CONGENITAL CLUBFOOT IN CHILDREN: Idiopathic talipes varus can be suspected from the fetal ultrasound. Parents should be given precise information concerning proposed treatment after birth. Deviations must be assessed in the newborn then revised regularly using objective scales during and after the end of treatment. This enables a better apprehension of the evolution in comparison with the severity of the initial deformation. Conservative treatment is proposed by many teams: a functional approach (rehabilitation and minimal use of orthetic material) or the Ponseti method (progressive correction using casts associated with percutaneous tenotomy of the calcaneal tendon) are currently preferred. If such methods are insufficient or unsuccessful, surgery may be performed as needed at about 8 to 11 months to achieve posteromedial release. Good results are obtained in 80% of patients who generally present minimal residual deformations (adduction of the forefoot, minimal calcaneal varus, residual medial rotation, limitation of dorsal flexion), which must be followed regularly through growth. The difficulty is to distinguish acceptable from non-acceptable deformation. At the end of the growth phase, severe articular sequelae are rare (stiff joint, recurrence of initial deformation, overcorrection) but difficult to correct surgically: osteotomy, tendon transfer, double arthrodesis, Ilizarov fixator. Gait analysis is essential to quantify function and obtain an objective assessment of the impact on higher joints, providing valuable guidance for surgical correction. OUTCOME IN ADULTHOOD: There have been very few studies evaluating the long-term functional outcome after treatment during childhood. According to two studies presented at this symposium (Brussels, Lausanne), results have been generally good but with subnormal radiographs irrespective of the type of treatment or how early treatment started in childhood. Hypoplasia of the talar dome is a constant finding and is correlated with limitation of dorsal flexion of the ankle joint. A small degree under-correction is often observed but well tolerated while overcorrection is generally less well tolerated. Functional outcome depends highly on preservation of subtalar joint motion. There have been no reports on the results of treatment of sequelae in adults. Most problems (pain, stiffness, osteoarthritis) are observed in the mid or rear foot. Indications for conservative surgery (osteotomy) of the mid or rear foot are rare compared with indications for combined arthrodesis. Talocrural decompensation is a turning point observed in the adult. Management at this point is difficult: fusion of the ankle worsens the situation by increasing the stress on the forefoot and aggravating the disability; implantation of an ankle prosthesis is technically difficult and remains to be fully developed. Treatment of the dorsal bunion of the great toe may require tendon transfer and/or fusion. CONCLUSION: A child born with clubfoot will never have a normal foot in adulthood. Sequelae present at the end of growth will intensify during adult life; under-correction is easier to treat in adulthood than overcorrection. The most difficult problems in adulthood are: neglected clubfoot, over correction, and degradation of the talocrural joint.

Primary adhalinopathy (alpha-sarcoglycanopathy): clinical, pathologic, and genetic correlation in 20 patients with autosomal recessive muscular dystrophy.

Primary adhalin (or alpha-sarcoglycan) deficiency due to a defect of the adhalin gene localized on chromosome 17q21 causes an autosomal recessive myopathy. We evaluated 20 patients from 15 families (12 from Europe and three from North Africa) with a primary adhalin deficiency with two objectives: characterization of the clinical phenotype and analysis of the correlation with the level of adhalin expression and the type of gene mutation. Age at onset and severity of the myopathy were heterogeneous: six patients were wheel-chair bound before 15 years of age, whereas five other patients had mild disease with preserved ambulation in adulthood. The clinical pattern was similar in all the patients with symmetric characteristic involvement of trunk and limb muscles, calf hypertrophy, and absence of cardiac dysfunction. Immunofluorescence and immunoblot studies of muscle biopsy specimens showed a large variation in the expression of adhalin. The degree of adhalin deficiency was fairly correlated with the clinical severity. There were 15 different mutations (10 missense, five null). Double null mutations (three patients) were associated with severe myopathy, but in the other cases (null/missense and double missense) there was a large variation in the severity of the disease.

Ultrasonographic approach to the neonatal foot: preliminary study.

We report our preliminary experience with use of ultrasound in clubfoot and describe our protocol and initial results in the use of this technique.

[Echography of the foot in newborn infants. Preliminary study]. / L'échographie du pied du nouveau-né. Etude préliminaire.

Xrays are of a poor help in the diagnosis of the deformities of the foot in the neonate. As a modern imagying, ultrasounds allow to show the cartilaginous frames and also the soft-tissues. Some special views are used which can give interesting informations about the abnormal connexions of the hindfoot and also the midtarsal joint. This procedure is also used for the follow up during the treatment in order to appreciate its efficiency.

[Value of ultrasonic diagnosis in the evaluation of hip dislocation in neonates and infants. Apropos of 340 cases]. / Valeur de l'échographie dans le bilan de la maladie luxante de la hanche du nouveau-né et du nourrisson. A propos de 340 cas.

Ultrasound imaging of hip (UIH) was performed in 170 children (340 hips) with normal (193) and dysplasic (147) hips and findings compared with results of clinical and radiologic examinations. Ultrasound demonstrated 100% sensitivity in cases with abnormal clinical and radiologic finding, and 94% specificity for UIH when clinical and radiologic examinations were negative. Sensitivity and specificity of ultrasound screening (respectively 96 and 81%) were comparatively superior to those of radiography of the pelvis (83 and 78%) in relation to the clinical examinations. These findings predict further development of UIH for screening of congenital dislocation of the hips and for follow up surveillance of treated children.

The functional anatomy of clubfoot.

The authors have studied anatomical specimens and findings at time of surgery to determine the functional anatomy of clubfoot. The importance of the midtarsal joints (especially of the talonavicular joint) is emphasized as well as the importance of the tibialis posterior. The findings of the authors concerning the function of these elements have allowed them to develop a new approach to the treatment of clubfoot.

[Study of the foot ground pressure pattern in children (author's transl)]. / Etude de l'appui plantaire chez l'enfant par photo-élastométrie.

The use of a new apparatus has enabled the authors to study the distribution to the ground of the plantar pressures by the way of ciphering each support area. This procedure is valuable and very precise as 500 pressure pick-up are used which give reliable, numerous and regularly distributed informations. The normal footprint has first been evaluated. Then, a comparison was possible with pathologic foot, so it was possible to estimate the result of a functional or surgical treatment on the morphology of the foot.