Periosteal preservation: a new technique in resection of bone high-grade malignant tumors in children-about eleven cases.

OBJECTIVE: The purpose of this study was to describe a surgical technique of bone resection with periosteal preservation and reconstruction in patients with high-grade bone malignant tumors and to determine its effect on local recurrences, and time and quality of bone union in bone autografting reconstruction. PATIENTS AND METHODS: We retrospectively reviewed 11 cases of high-grade malignant bone tumors in children aged 4 to 16 years, who were treated with chemotherapy and tumor resection while preserving partially the adjacent periosteum. Tumors were located in the lower limb in eight cases; three tumors were in the humerus. The mean length of the bone defect after resection was 15.8 cm (range, 6-34.5 cm). Reconstruction was provided by non-vascularized autograft in eight cases (lower limb) and polymethyl methacrylate spacer in three cases (upper limb). Patients were followed up for a mean of 71 months. RESULTS: At the last follow-up, no patients had local recurrence. Three patients were dead because of metastasis. Bone union was good in time and quality in all children who had bone autografting. In cases of PMMA reconstruction, there was periosteal bone formation around the spacer. According to the MSTS functional score, patients with lower limb localizations had a mean score of 27.75 points and patients with upper limb localizations had a score of 24/30. CONCLUSION: Preservation of the periosteum in bone resection for malignant tumors could be a good adjuvant alternative for bone reconstruction, without increasing the risk of local recurrence. However, patients must be carefully selected.

Cavernous hemangioma of the forearm muscles: Three case reports and literature review.

Introduction: Hemangiomas are common benign vascular tumors. Intramuscular hemangioma is a very rare type of hemangioma occurring in the skeletal muscle. The lower limb muscles are more likely to be affected. The location within the muscles of the forearm is extremely rare. Case Report: We present three cases of intramuscular hemangioma of the upper limb. Magnetic resonance imaging (MRI) revealed a vascular tumor within the pronator teres muscle in two cases and the extensor pollicis brevis muscle in the other. The tumors were surgically excised, and histopathologic examination confirmed the diagnosis of intramuscular cavernous hemangioma. The limb function was good and there was no recurrence at 12-month follow-up in the three cases. Conclusion: Intramuscular hemangiomas of the forearm are a condition that should be evoked by orthopedic surgeons in front of pain and swelling of this region. MRI is the most effective imaging method to suspect the diagnosis.

Multi slice computed tomography approach in the assessment of supracondylar humeral fractures in children.

The purpose of this study was to assess the impact of Multi Slice Computed Tomography (MSCT) on the understanding of the spatial displacement of supracondylar humeral (SCH) fractures, their classification and their management. A prospective study was conducted on 63 children with SCH fractures Gartland II or Lagrange 2 and 3, over a period of 30 months. The patients were 42 boys and 21 girls, aged between 3 and 14. All patients were imaged using conventional radiography. Thirty-two patients underwent MSCT and 3-dimensional reconstructions. According to the Lagrange classification system, 16 patients had type 2 fractures and 47 had type 3 fractures. In type 2, the posterior cortices of both medial and lateral columns were bent on CT (n = 6). In type 3, CT-scan made it possible to distinguish two subgroups. In the first subgroup (n = 12) there was fracture of both anterior and posterior cortices of the lateral column; however, the posterior cortical surface of the medial column was preserved. In the second subgroup (n = 14), there was no cortical surface contact in the medial column, but the continuity of the posterior cortical surface of the lateral column was preserved. Based on a new concept of column stability, the use of CT-scan has allowed for a better understanding of supracondylar fractures in children.

[Epidemiology of acute hematogenous osteomyelitis in children: a prospective study over a 32 months period]. / Epidémiologie des ostéomyélites aiguës hématogènes communautaires de l'enfant : Etude prospective sur 32 mois.

AIM: To determine the demographic, clinical, biological and bacteriological profile of acute community acquired hematogenous osteomyelitis (AHO) in children. METHODS: Prospective study including children admitted for AHO. We noted the demographic parameters of patients and the clinical, biological and radiological characteristics of the infection. Blood cultures and local specimen in operated children were systematically performed. RESULTS: 70 patients were included. The mean age was 7.7 years. The mean time between onset of symptoms and admission was 3.2 days. Distal tibia was the most frequent localization (18.66%). Fever higher than 38° on admission was found in 92.8% of patients. Creactive protein (CRP) was superior to 20 mg / L in 95.8% and ESR superior to 20 mm in the first hour in 92% of cases. A deep venous thrombosis was found in 7 patients and a pleuropulmonary Staphylococcus infection in 4 patients. A micro organism was isolated in 64.7% of cases. Staphylococcus aureus methicillin susceptible (SAMS) was the predominant germ. Staphylococcus aureus methicillin resistant (SAMR) accounted for 15.7% of staphylococcus aureus infections. The importance of CRP on admission and time to resolution of fever after the start of treatment were significantly higher in SAMR infections. The existence of deep venous thrombosis and a pleuropulmonary Staphylococcus infection and the need for surgical drainage were significantly more frequent in SAMR infections. CONCLUSION: The existence of a severe form of AHO should lead to a high suspicion of SAMR infection and prompt the prescription of an appropriate antibiotiotherapy.

About a misleading calcified mass of the elbow: Soft tissue osteochondroma: A case report.

INTRODUCTION: Soft tissue osteochondromas are rare lesions, with a misleading radiology, that can present diagnostic dilemma. CASE PRESENTATION: We report the case of 16-year-old girl who presented an anterior swelling in his left elbow, slightly painful on palpation, with no signs of inflammation. Elbow mobility was normal. Standard radiographs showed a globular calcified mass. CT scan revealed a well-defined lobulated soft tissue mass with extensive flaky calcification. Magnetic resonance imaging (MRI) showed lobulated and intermuscular non-enhancing mass. The lesion had a low heterogeneous signal on T1 images, and a high heterogeneous signal on T2 FAT-SAT images, with low signal areas suggesting calcifications. There was no continuity to the adjacent ulna and radius. The patient first underwent image-guided core needle biopsy and histological examination concluded to chondroma. The tumour was then resected by anterior approach and the final histological diagnosis was osteochondroma of soft tissue. DISCUSSION: A diagnosis of extraskeletal osteochondroma should be considered when an ossified mass is localized in the soft tissue particularly on the elbow. Excision is the treatment of choice when the function is reduced and the nature of the tumour remain uncertain. CONCLUSION: Orthopedic surgeons should know about elbow localization of osteochondromas to help in accurate diagnosis and management of the tumour, to avoid overtreatment.

Childhood soft tissue chondroma. Two cases report.

BACKGROUND: Soft tissue chondroma is a rare benign tumour, which is generally seen in adult. It consists of islands of heterotopic cartilaginous tissue and most localised on the hands and the feet. The hypothesis that microtrauma is involved in the aetiology of this condition has yet to find any factual support. AIM: To report two paediatric cases of soft tissue chondroma. CASES REPORT: The first is a soft tissue chondroma of the posterior aspect of the left axilla in a 3-year-old boy. CT scans showed a spherical fatty density soft tissue mass without evident calcifications, attaching the infraspinous muscle. The second patient is a 9-year-old girl presented with a right auricular finger soft tissue chondroma. Radiographs showed several punctuated calcifications with adjacent bone scalloping. MRI revealed a lobulated soft tissue mass attaching the flexor tendons. The tumours were entirely removed. Histological examination showed cartilaginous tissue in both cases. At follow-up, the patients had good functions without evidence of recurrence. CONCLUSION: Simple excision should suffice to treat soft tissue chondroma but care should be taken to make the excision complete if recurrence are to be avoided.

About a rare cause of calf pain in an athlete: the popliteal artery entrapment syndrome (a case report).

Claudication of the young patient is a very rare symptom for orthopaedic surgeons and it is often overlooked. We report a rare case of popliteal artery entrapment syndrome (PAES), discovered during a vascular claudication following post-traumatic anterior instability of the knee. The diagnosis was confirmed by CT angiography which showed a PAES, with a pathway in the inter-condylar notch. The patient had a releasing of the trapped vessel by myomectomy, with disappearance of vascular symptoms six months later. Through this case, we wanted to draw the attention of orthopaedic surgeons to the fact that the PAES can be asymptomatic. Its symptomatology can be triggered by a traumatic instability of the knee. Its presence represents a risk of lesion of the popliteal artery during arthroscopic ACL reconstruction. Therefore, it is important to think about this disease if a calf pain occurring after a ligament injury of the knee.

Pseudocystic Osteosarcoma: A Potential Diagnostic Pitfall - Case Report.

INTRODUCTION: Pseudocystic osteosarcoma (OS) is an uncommon variant of conventional OS. Clinical and radiological features are presented as benign process with a non-rapid growth rate. Treatment may be adversely affected by the delay in diagnosis or an appropriate invasive procedure. CASE PRESENTATION: We report a rare case of pseudocystic OS of the distal femur in a 6-year-old boy. Imaging findings revealed an osteolytic intra-compartmental tumor, that suggested either simple bone cyst or subacute osteomyelitis. The patient was first operated by lateral approach for curettage but histopathology showed conventional OS. Treatment had been managed by standard current chemotherapy and trans-epiphyseal intercalary resection through lateral approach. Reconstruction was done by a non-vascularized autograft within the induced membrane technique. At 3 years of follow-up, the patient remained disease-free with good anatomical and functional results. CONCLUSION: conventional OS can be presented in rare cases as a benign bone cyst tumor. This type of pseudocystic OS should be included in the differential diagnosis of bone cyst tumors and pseudo-tumors.

An unusual cause of shoulder pain: osteochondroma of ventral scapula (a case report).

Osteochondromas mainly affect the metaphysis of long bones such as femur, humerus, and tibia. It is unusual in flat bones such as scapula. Osteochondroma of ventral surface of scapula is one of the rare cause of shoulder pain and difficult to diagnose in first place. We report the case of an 18-year old girl, presenting progressive right shoulder pain for two years. Physical examination showed an imbalance of the shoulders, a winging of the right scapula, and a snapping of the shoulder on mobilization. Radiographic evaluation showed a pedunculated bony structure extruding from the scapula. Computed tomography (CT) scanner and magnetic resonance imaging (MRI) revealed a bony exostosis along the medial border on the ventral surface of the right scapula. The patient had an excision of the exostosis. Histologic examination confirmed that the specimen was an osteochondroma with no signs of malignant transformation. The shoulder was immobilized for two weeks. The patient has regained full function of her shoulder, six weeks postoperatively.

Magnetic resonance evaluation of acetabular residual dysplasia in developmental dysplasia of the hip: a preliminary study of 27 patients.

Thirty-one hips in 27 young girls, treated for developmental dysplasia of the hip in the authors' institute since 2003, showed persistent radiographic evidence of residual acetabular dysplasia. These hips were registered as candidates for pelvic osteotomy. A prospective study was conducted and these hips were evaluated by magnetic resonance imaging (MRI); the average age of the patients was 5 years. MRI measurement of acetabular angle and acetabular head index in 2 different landmarks (bone and cartilage) was performed. The results were correlated with plain radiographic film evolution. MRI studies revealed sufficient cartilaginous acetabular coverage in 27 hips, cartilaginous acetabular dysplasia in 2 hips, and short acetabulum in 2 others. The 27 hips with thick cartilage of the acetabular roof were subsequently followed up by plain radiographs. The average follow-up period was 2.1 years. The authors observed a spontaneous progressive ossification of the cartilaginous acetabular roof in all the 27 cases. In 4 cases, the correction of the acetabular angle was complete. They concluded that MRI promotes more accurate selection of patients for pelvic osteotomy and aids in the choice of the most appropriate type of osteotomy. Clinical imaging examples are presented and need to be further evaluated.

Imaging of benign lipomatous tumours of the limbs in children.

BACKGROUND: Lipomatous tumours of the limbs in children are rare, and lipoblastoma is the most common soft tissue tumour. Most of them have typical imaging features, but their clinical presentation and their management may vary, depending on the exact histological subtype. The aim of our study is to illustrate the main clinical, radiological and histological features of the different benign lipomatous tumours in children. METHODS: Review of the literature. RESULTS: It is about a descriptive study of paediatric cases of benign lipomatous tumours of limb in children. CONCLUSION: The imaging findings are helpful and can provide essential components for the diagnosis.

Early results of the Ponseti method using the Steenbek foot abduction brace: a prospective study of 95 feet.

The purpose of this study is to evaluate the early results of the Ponseti method and the effectiveness of the Steenbek foot abduction brace. A total of 74 patients with 110 idiopathic clubfeet were included in this prospective study. The feet were evaluated according to the Dimeglio-Bensahel classification, the Catteral-Pirani classification and the functional classification of the Hospital for Joint Diseases. Ninety-eight feet (89%) had a good result after the casting period. All the feet evaluated after the period of full-time bracing and during the period of part-time bracing showed a good correction. The Ponseti method using the Steenbek foot abduction brace is effective in correcting idiopathic clubfeet.

Idiopathic tumoral calcinosis.

Idiopathic tumoral calcinosis is an unusual benign condition characterized by the presence of calcified soft tissue masses of varying size around the joints. In this retrospective study,clinical data and radiological features of nine cases of idiopathic tumoral calcinosis are reviewed. Imaging features, particularly magnetic resonance imaging findings are detailed.

[The proximal humeral osteotomy associated with the transfert of Latissimus Dorsi and Teres major in treatment of sequelae of the obstetrical brachial plexus]. / L'ostéotomie humérale proximale associée au transfert du latissimus dorsi et teres major dans le traitement de certaines séquelles tardives de la paralysie obstétricale du plexus brachial.

BACKGROUND: Shoulder sequelae of obstétrical brachial plexus palsy put a different problem of coverage according to the age of the patients and the presence or not of ostéo-articular deformations. At an advanced age and in the presence of ostéo-articular deformations, the muscles liberation and transfers tendineux only are insufficient for the restoring of a satisfactory function to the paralytic shoulder. AIM: The purpose of this study is to report an original technique by the association of libertation of retracted muscles and a humeral osteotomy to improve the abduction and to acquire an active external rotation in internal rotation retraction of the shoulder sequelae of obstétrical brachial plexus palsy. METHODS: This retrospective study concerned twelve patients admitted in the service of Childish Orthopaedics of Children's hospital of Tunis between 1997 and 2003. The average age of the patients are 11 years. All the patients have a proximal humeral osteotomy above the deltoïdien V with a desinsertion of the Subscapularis and to the transfer of the Latissimus Dorsi and Teres Major, realized by a single posterior approch. RESULTS: After a mean follow up of 48 month a frank aesthetic and functional improvement was noted in every case. CONCLUSION: The importance of retraction for an advanced age, made that an humeral osteotomy of external derotation is necessary. Have a practice above the deltoïdien V it allows to improve at the same time the external rotation and the abduction due to the lateral translation of the deltoid. This last one is strengthen by the désinsertion of a retracted Subscapularis and levying of the co-contractions of the Latissimus Dorsi and Teres major with the deltoid almost constant.

BROMETH: Methodology to design safe reconfigurable medical robotic systems.

BACKGROUND: This research paper deals with the development of a medical robotized control system for supracondylar humeral fracture treatment. Concurrent access to shared resources and applying reconfiguration scenarios can jeopardize the safety of the system. METHODS: A new methodology is proposed in this paper, termed BROMETH, to guarantee the safety of such critical systems from their specification to their deployment, and passing through certification and implementation. The solution is applied to a real case study named Browser-based Reconfigurable Orthopedic Surgery (abbrev. BROS), a robotized platform dedicated to the treatment of supracondylar fractures, to illustrate the paper's contribution. This work starts from a medical issue, namely supracondylar humeral fracture treatment, to establish a new informatics solution, namely a new methodology to design safe reconfigurable medical robotic systems. RESULTS: The results of the experiments performed on real SCH fracture radiographies were quite satisfactory. CONCLUSIONS: Clinical experiments can then be performed after deploying the system on real hardware.

[Battered child syndrome: clinical and radiological aspects]. / Le syndrome des enfants battus: aspects cliniques et radiologiques.

Physical child abuse or battered child syndrome is responsible for over 75.000 deaths per year in France. This public health problem is under-diagnosed in Tunisia and in the world. The path toward the recognition of battered child syndrom was arduous even in some western societies. This study aims to highlight this problem to healthcare practitioners in order that accurate diagnosis and appropriate management may be provided. Physical child abuse has wrongly been referred to as Silverman syndrome that includes only skeletal lesions in children such as fractures.

Bone diseases in children receiving growth hormone.

The authors report two cases of bone disorders in children with short stature, with confirmed growth hormone (GH) deficiency treated by GH supplementation. The first patient, aged 15 years, developed avascular necrosis of the femoral head and scoliosis. The second one, aged 17 years, had avascular necrosis of the femoral capital epiphysis on one side and acute slipped capital femoral epiphysis (SCFE) on the other side. All these complications were diagnosed while they were receiving GH-therapy. The exact aetiology and the role of GH in the pathogenesis of these conditions are still unknown.

Septic arthritis of a lumbar facet joint case report and review of the literature.

Septic arthritis of a lumbar facet joint (SALFJ) is a very rare condition. It has mostly been described in adults. Only one other paediatric case has been reported. We present a case of septic arthritis of the left L5-S1 lumbar facet joint, associated with epiduritis and paraspinal abscess, in an 8-year-old boy. Plain radiographs and Technetium bone scan were negative. The diagnosis was made by blood cultures, which isolated staphylococcus epidermidis, and by MRI. The child was treated successfully with antibiotics only.