An original preoperative orthopaedic management of a complex spinal deformity in a 16-year-old patient with spondyloepiphyseal dysplasia congenita.

PURPOSE: Spinal deformities in patients with Spondyloepiphyseal Dysplasia congenita are particularly challenging to treat. Addressing these deformities requires a holistic surgical strategy. The aim of this case report is to highlight an original preoperative protocol combining atlantoaxial instability stabilization by halo jacket with progressive correction of a thoracic kyphoscoliosis using continuous elongation by tension plaster cast as described by Stagnara. METHOD: A 16-year-old patient with spondyloepiphyseal dysplasia congenita presenting a severe thoracic kyphoscoliosis associated with atlantoaxial instability causing cervical myelopathy was managed through a preoperative protocol combining a halo jacket with a Stagnara elongation cast allowing progressive correction of the kyphoscoliosis while stabilizing the cervical instability. RESULTS: The preoperative protocol allowed a safer and a more effective surgical spine fusion, reducing neurological risks, improving the final correction, and offering better postoperative recovery. Clinical and radiological solid fusion was observed at 3-year-follow-up with significant improvement of the patient's quality of life. CONCLUSION: This case report highlights the effectiveness of the preoperative preparation combining a halo jacket with a Stagnara elongation cast to safely stabilize the cervical spine while correcting the thoracic kyphoscoliosis. This strategy can serve as a valuable tool for spine teams when addressing complex spinal deformities particularly in this patient with SEDc. LEVEL OF EVIDENCE: Level IV.

Posterior cruciate ligament avulsion associated with an epiphyseal fracture of the proximal fibula: a case report of a 13-year-old child.

Posterior cruciate ligament (PCL) avulsion fractures are rare among the pediatric population. Reported PCL injury incidence varies from 1 to 40% depending on the study population. PCL lesions can be isolated or associated with other ligamentous lesions, which makes their management challenging. Knee ligament reconstruction is essential to restore knee stability and, thus, prevent future menisci and cartilage degeneration. However, surgical management of these injuries can lead to subsequent iatrogenic growth disturbances. Case presentation: The authors describe the case of a 13-year-old child involved in a sports accident causing a PCL avulsion fracture associated with an epiphyseal fracture of the proximal fibula resulting from an incomplete peel-off injury of the lateral collateral ligament. The patient was scheduled for open reduction and internal fixation on the same day of the presentation. A long-leg cast was then applied for 6 weeks. By 3 months postoperatively, the patient regained full range of motion, and return to sport was possible 6 months after the surgery. Conclusion: In children and adolescents, PCL avulsion fractures are often associated with other occult lesions. Although good functional and clinical outcomes using operative management for these lesions are reported, specific treatment recommendations are lacking in skeletally immature patients.

Structural scoliosis secondary to thoracic osteoid osteoma: a case report of delayed diagnosis.

PURPOSE: The aim of this case report is to show that late diagnosis of vertebral osteoid osteoma gives rise to structural scoliosis which sometimes requires long-term management. METHODS: We report a case of an osteoid osteoma in the thoracic spine associated with structural scoliosis. We describe a 14-year-old boy who complained chronic nightly left back pain and scoliosis. Spine's X-ray was reported thoraco-lumber scoliosis without bone lesion. RESULTS: MRI as well as technetium-99 m total body bone scan and a computed tomography scan revealed a bony lesion in the upper left joint of T11 vertebra consistent with the diagnosis of OO. Anatomopathological study of the resection piece confirmed the diagnosis of OO. Surgical excision of the tumor resolved pains, but scoliosis needed an orthopedic treatment for 1 year. CONCLUSION: Through this case, it has been demonstrated that late diagnosed vertebral OO can be the cause of structural scoliosis. Clinical and radiological results indicate that OO resection is an effective and safe method of treatment. LEVELS OF EVIDENCE: IV.

Cranio-cervical decompression associated with non-instrumented occipito-C2 fusion in children with mucopolysaccharidoses: Report of twenty-one cases.

Background: Mucopolysaccharidosis (MPS) is a multisystemic storage disorder of glycosaminoglycan deposits. Infiltration of the dura mater and supporting ligaments caused spinal cord compression and consecutive myelopathy, especially at the cranio-cervical junction (CCJ). Craniocervical instability and posterior decompression often raise the problem of fixation in children. The main purpose of this paper was to report the result of an original technique of occipito-cervical arthrodesis using a cranial halo-cast system in pediatric population. Methods: We recorded 21 patients with cervical myelopathy. All of them had spinal cord decompression by enlargement of the foramen magnum, C1 laminectomy, and occipito-C2 fusion using corticocancellous bone graft. Only one child has an extended laminectomy from C1 to C3. The occiput-C2 arthrodesis was stabilized by the cranial halo-cast system. This immobilization was performed preoperatively and kept for three months then switched to rigid cervical collar. Clinical assessment, including the Goel grade and mJOA, radiographs and magnetic resonance imaging were performed before surgery. The occipito-cervical arthrodesis was controlled by standard X-rays and CT scan. Results: According to the type of mucopolysaccharidosis, the patients were divided into MPS type I: n= 3, II: n=7, IV: n=11. The mean age of patients at surgery was 6.76 years. All mucopolysaccharidoses cases required a foramen magnum decompression by craniectomy, C1 laminectomy and occipito-C2 arthrodesis. As major complications, a child had immediate post-operative paraplegia due to spinal cord ischemia. The postoperative follow-up ranged from 1.5 to 4 years, with an average of 3.3 years. The average preoperative mJOA score was 8.9, and it improved to 14 points at the last follow-up. Conclusions: Satisfactory fusion and good clinical results were obtained with the 2-stage approach to CCJ anomalies.

Ankle sprain injury in child and adolescent: Diagnostic pitfalls.

Introduction and importance: Sprained ankles in children and adolescents are rare. Certain diagnostic pitfalls must arise in the mind of the clinician because many differential diagnoses must be confirmed or refuted urgently. Among them, the infectious osteoarticular pathology including acute hematogenous osteomyelitis of the tibia or distal fibula and septic arthritis of the subtalar joint.The main purpose of this work, through four clinical cases, we will discuss diagnostic pitfalls in the course of ankle trauma in children and adolescents. Case presentation clinical: In this work, we have demonstrated through four cases some diagnostic errors in the context of ankle trauma in children and adolescents. Infectious and malignant tumor pathologies are real diagnostic and therapeutic emergencies. For all these cases, the initial diagnosis was a sprained ankle following a gambling or sports accident. Discussion: Ankle trauma in children and adolescents is a frequent reason for consultation in emergencies. The fear of the orthopedic surgeon is to miss a serious pathology and wrongly make the simple diagnosis of a sprained ankle. Temperature measurement must be systematic. The clinical examination must be meticulous. The interpretation of the radiograph must be cautious. Acute hematogenous osteomyelitis and malignant tumor pathology should be on the surgeon's mind. Conclusion: We have shown through these four examples that a serious pathology can simulate a sprain. Hence, a careful analysis of clinical, biological and radiological elements is the only guarantee of adequate care.

Acute hematogenous osteomyelitis in children: Management of pandiaphysitis with extensive bone destruction: A case series of thirteen child.

Introduction: and Importance: Acute hematogenous osteomyelitis (AHO) poses a public health problem in severe forms from the outset or with delayed diagnosis. The aim of this work is to describe the management of pandiaphysitis with extensive bone destruction by the Ilizarov external fixator and antibiotics and to evaluate the results. Methods: This is a retrospective, descriptive, cross-sectional and single-center study. It was performed over a seven-year period. We included children with acute hematogenous osteomyelitis complicated by pandiaphysitis of the long bones with extensive bone necrosis. All patients underwent stabilization with an Ilizarov external fixator and antibiotic therapy adapted to the antibiogram in ten cases. One patient had the induced membrane technique. All the patients underwent dynamization of the Ilizarov external fixator followed by immobilization with a cast or a splint for the lower limb. Outcomes: 13 medical files were collected during the study period. The sex ratio was 1.6, the average age was 7.56 years. Three localization sites: humerus for 3 cases, femur for 3 cases and tibia for 7 cases. The germ has been identified in ten cases. Methicillin-resistant staphylococcus aureus was the most common. Bone consolidation is obtained in all cases with an average delay of ten months. Conclusion: The Ilizarov external fixator associated with antibiotics has proven its effectiveness in the management of pandiaphysitis with extensive bone destruction. This method is an alternative in the therapeutic arsenal available to pediatric orthopedic surgeons. Level of evidence: IV, Case series.

Calcaneal lengthening osteotomy in the management of idiopathic flatfoot in children: cCase series of twenty-one feet.

INTRODUCTION: Flatfoot is a frequent reason for consultation in pediatric orthopedics. The calcaneal lengthening osteotomy according to the EVANS technique is a therapeutic alternative. The objective of this work was to evaluate the short and medium term clinical and radiological results of calcaneal lengthening osteotomy in children with idiopathic flat foot valgus. METHODS: This study concerned 12 children and 15 ft treated surgically by calcaneal lengthening osteotomy by an orthopedic surgeon in a pediatric orthopedic surgery center. The evaluation of the results was clinical according AOFAS score and radiological. RESULTS: The deformity was reducible in all of our patients. The mean preoperative AOFAS score was 61, postoperatively 90. The overall result was excellent in 11 cases (11 ft) and good in 4 cases. The postoperative radiological result was close to normal values. CONCLUSION: Calcaneal lengthening osteotomy is a reliable and recommended technique for the correction of symptomatic idiopathic flatfoot. LEVEL OF EVIDENCE: IV, Case series.

Subacute osteomyelitis of the tibial diaphysis associated with Brodie's abscess: A rare case report of a four-year-old child.

INTRODUCTION: Septic osteomyelitis is a hematogenous bacterial bone infection. The acute presentation is the most common; the subacute one is less frequent. The aim of our case report is to put forward the features of this uncommon presentation and to propose a therapeutic management. PRESENTATION OF CASE: We report a rare case of subacute osteomyelitis associated with Brodie's abscess of the tibial diaphysis in a four-year-old child. The chief complaint was a pain in the left tibia evolving for five weeks. The radiological findings and the unusual location of this pathology suggested a malignant bone tumor. Thanks to imaging assessment and bone biopsy the diagnosis of subacute osteomyelitis associated with Brodie's abscess was made. Therefore, the child had antibiotic therapy and plaster immobilization to avoid pathological fracture. Pain relief and radiological improvement was obtained after 3 months of antibiotic treatment. At a two-year follow-up, the X-ray was normal. DISCUSSION: We report an uncommon case of subacute osteomyelitis which evolved to Brodie's abscess with diaphyseal location. The mainstream treatment is surgery combined with antibiotics. However, medical treatment alone can lead to recovery without sequelae. CONCLUSION: Because of the atypical location and presentation of subacute osteomyelitis, the other differential diagnoses, especially malignant bone tumors have to be eliminated. In some cases, treatment may be based on antibiotics therapy alone.

Infected primary hydatid cyst of the right lumbar paraspinal muscles: A rare case in a ten-year-old child.

INTRODUCTION AND IMPORTANCE: Most of the time, intramuscular hydatid cysts are secondary. The unusual topographies are a source of diagnostic delay and treatment difficulties. The aim of our case report is to put forward the features of this uncommon presentation and to propose a therapeutic management. CASE PRESENTATION: We report the case of a primary hydatid cyst located in the right lumbar paraspinal muscles in a ten-year-old girl, in good health and without a pathological medical history. The patient presented with a discreet right lumbar swelling of firm consistency, painless and without signs of inflammation. Ultrasound and magnetic resonance imaging suggested the diagnosis of an intramuscular paravertebral hydatid cyst. The hydatid serology was positive. The patient had en-bloc resection of the cyst. He was infected with pus. The histopathological examination confirmed the diagnosis of muscular hydatidosis. Medical treatment was started. Three years after the operation, the MRI confirmed that was no recurrence. CLINICAL DISCUSSION: Echinococcus is a parasitic cestode that can infect dogs and other pets and farm animals, with humans as incidental hosts. Muscular hydatid localization, secondary to hematogenous dissemination, is rare, even in endemic countries. The combination of medical treatment with surgery ensures the best condition to avoid recurrence. CONCLUSION: In regions where hydatidosis is endemic, a tumor in any part of the body should be considered a hydatid cyst until proven otherwise.

Biogenesis of a Bacteriophage Long Non-Contractile Tail.

Siphoviruses are main killers of bacteria. They use a long non-contractile tail to recognize the host cell and to deliver the genome from the viral capsid to the bacterial cytoplasm. Here, we define the molecular organization of the Bacillus subtilis bacteriophage SPP1 ~ 6.8 MDa tail and uncover its biogenesis mechanisms. A complex between gp21 and the tail distal protein (Dit) gp19.1 is assembled first to build the tail cap (gp19.1-gp21Nter) connected by a flexible hinge to the tail fiber (gp21Cter). The tip of the gp21Cter fiber is loosely associated to gp22. The cap provides a platform where tail tube proteins (TTPs) initiate polymerization around the tape measure protein gp18 (TMP), a reaction dependent on the non-structural tail assembly chaperones gp17.5 and gp17.5* (TACs). Gp17.5 is essential for stability of gp18 in the cell. Helical polymerization stops at a precise tube length followed by binding of proteins gp16.1 (TCP) and gp17 (THJP) to build the tail interface for attachment to the capsid portal system. This finding uncovers the function of the extensively conserved gp16.1-homologs in assembly of long tails. All SPP1 tail components, apart from gp22, share homology to conserved proteins whose coding genes' synteny is broadly maintained in siphoviruses. They conceivably represent the minimal essential protein set necessary to build functional long tails. Proteins homologous to SPP1 tail building blocks feature a variety of add-on modules that diversify extensively the tail core structure, expanding its capability to bind host cells and to deliver the viral genome to the bacterial cytoplasm.

The "Patient management problem" as a formative evaluation during the internship.

INTRODUCTION: The evaluation of the internship in pediatric orthopedics is based on a clinical examination in the form of ECOS, after the internship period involving all surgical specialties. The validation of the clinical examination test does not necessarily mean that the student has achieved his internship objectives and vice versa. This discrepancy between the evaluation test and the field of the internship prompted us to question the need to establish a formative evaluation method during the clinical internship. METHODS: Our study is a prospective, evaluative, longitudinal study, from October 2019 until September 2020, in the infantile orthopedics and traumatology department of the "Béchir HAMZA" children's hospital in Tunis. We carried out a formative evaluation using the "Patient Management Problem" (PMP), with two different subjects, one on acute hematogenous osteomyelitis, the other on malignant bone tumors, with a Pre-test and a Post-test for each PMP. RESULTS: We had 18 interns, during the period between October 2019 and September 2020, including 13 who had medical training in Tunisian faculties. The score for the acute osteomyelitis pretest was 14.56 on average, the PMP score was 16.33 on average, with one interne scoring zero. The posttest mean was 18.11 [13.75-20], with a statistically significant difference from the pretest. The pre-test for the bone tumors' PMP had an average of 9.7 [3.75-15], that of PMP was 12.6 [0-20]. There was an improvement in post test scores with an average of 16.45. Comparing the two tests we noticed that the scores for the PMP osteomyelitis were higher than the scores for the PMP bone tumors with a significant difference between the two groups (p = 0.04). CONCLUSIONS: The results of this pilot project are encouraging for the establishment of a continuous evaluation by the PMP method, intended for interne during the pediatric orthopedic surgery internship. This method allows learning and formative evaluation of learners by evaluating clinical and therapeutic reasoning.

Torticollis as a sign of spinal tuberculosis.

Bone localization of tuberculosis mainly affects the thoracolumbar spine. The cervical spine is rare. Its diagnosis is often late which exposes to great instability and potentially serious complications. We report the case of a 12-year old girl with no medical history, showing torticollis and high temperature without neurological complication. In the physical examination, he had torticollis and pain in the third, fourth and fifth cervical vertebra. When the biopsy was performed, we find an inter apophysis (between C7 and D1) collection. The histological examination confirmed the diagnosis of apophysis tuberculosis. The management based on tuberculosis chemotherapy and immobilization started as soon as possible.

Isolated tuberculosis of the navicular bone in a child.

Tuberculosis is a topical issue in endemic countries. Foot involvement is rare and accounts for 5-10% of all osteoarticular tuberculosis. Pediatric cases of osteoarticular tuberculosis are uncommon especially in well vaccinated children. The clinical presentation is not specific and can be confused with common germ like staphylococcus. Biopsy is mandatory in endemic zone, and if the evolution is not good with antibiotherapy. Debridement can be indicated but must be gentle, because of the risk of navicular necrosis.

Congenital pseudarthrosis of the forearm treated with induced membrane technique: A case report.

Congenital pseudarthrosis of the forearm (CPF) is an uncommon entity frequently described in association with neurofibromatosis type 1. Surgical treatment Is required. This is a challenging pathology in pediatric orthopedic surgery due to the difficulty of achieving a satisfying result in terms of bone defect healing. Many techniques are described such us free vascularized fibula, illizarov and induced membrane. We describe a first case of the forearm non union associated with neurofibromatosis type 1 successfully treated with 2 steps of induced membrane. Whatever the technique selected it's remain challenging problem in pediatric orthopaedic.

Kienböck's disease in an 11-year-old girl: a case report.

Kienböck disease is a pathology that remains uncommon in children, therefore the number of published cases of Kienböck's disease before skeletal maturity is limited. The etiology of Kienböck's disease is still controversial. Although many therapeutic methods are described in the literature. There is no consensus treatment for this pathology. We describe a case of Kienböck's disease of an 11-year-old girl who presented with avascular necrosis of the lunate bone confirmed by the radiologic pattern. And who was treated with 10 weeks of splinting with satisfying clinical outcome. Wrist pain and other symptoms resolved after 2 months. A magnetic resonance imaging (MRI) confirmed partial revascularization of the lunate. After 18 months of follow-up the patient remains asymptomatic.

The collagen-like protein gp12 is a temperature-dependent reversible binder of SPP1 viral capsids.

Icosahedral capsids of viruses are lattices of defined geometry and homogeneous size. The (quasi-)equivalent organization of their protein building blocks provides, in numerous systems, the binding sites to assemble arrays of viral polypeptides organized with nanometer precision that protrude from the capsid surface. The capsid of bacterial virus (bacteriophage) SPP1 exposes, at its surface, the 6.6-kDa viral polypeptide gp12 that binds to the center of hexamers of the major capsid protein. Gp12 forms an elongated trimer with collagen-like properties. This is consistent with the fold of eight internal GXY repeats of gp12 to build a stable intersubunit triple helix in a prokaryotic setting. The trimer dissociates and unfolds at near physiological temperatures, as reported for eukaryotic collagen. Its structural organization is reacquired within seconds upon cooling. Interaction with the SPP1 capsid hexamers strongly stabilizes gp12, increasing its Tm to 54 °C. Above this temperature, gp12 dissociates from its binding sites and unfolds reversibly. Multivalent binding of gp12 trimers to the capsid is highly cooperative. The capsid lattice also provides a platform to assist folding and association of unfolded gp12 polypeptides. The original physicochemical properties of gp12 offer a thermoswitchable system for multivalent binding of the polypeptide to the SPP1 capsid surface.